UC-NRLF 


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THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

PRESENTED  BY 

PROF.  CHARLES  A.  KOFOID  AND 

MRS.  PRUDENCE  W.  KOFOID 


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A   MANUAL 


OF 


MEDICAL  DIAGNOSIS: 


BEIXG 


AN    ANALYSIS 


OF 


THE  SIGXS  AND  SYMPTOMS  OF  DISEASE. 


By  A.  W.  BARCLAY,  M.  D. 

CASTAS.  ET  EDIX. 

FALLOW   OF   ME   ROTAL  COLLEGE  OF   PHYSICIANS;    ASSISTANT  PHYSICIAN 

TO   ST.  G£OKG£:S  HOSPITAL,   ETC.  ETC. 


PHILADELPHIA: 
BLANCHARD    AND     LEA, 

1858. 


TVM.  S.  YOUNG.  PRINTER. 


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PREFACE. 


In  adding  another  to  the  many  manuals  already  in  the  hands  of 
students,  a  few  words  of  explanation,  and  perhaps  of  apology,  are 
necessary. 

The  want  of  that  instruction  which  it  is  meant  to  convey  was  felt 
by  myself  in  the  commencement  of  my  studies,  and  many  diligent 
students  have  expressed  in  my  hearing  a  wish  for  some  guide  to  the 
systematic  investigation  of  cases  in  the  wards  of  the  hospital.  This 
branch  of  medical  study  has  been  very  successfully  cultivated  on 
the  Continent,  and  the  English  student,  while  conscious  of  a  culpa- 
ble neglect  of  the  curative  powers  of  remedies,  cannot  fail  to  be 
struck  with  the  precision  and  clearness  with  which  a  clinical  profes- 
sor in  Paris  conducts  the  examination  of  his  patients. 

When  in  1847,  the  duties  of  medical  registrar  were  intrusted  to 
me  by  the  governors  of  St.  George's  Hospital,  a  large  field  of  study 
in  this  department  was  opened  to  me:  by  the  kindness  and  courtesy 
of  the  physicians  I  was  always  assisted  in  deciding  on  the  nature 
of  an  obscure  case ;  while  the  examinations  after  death  so  constantly 
practised,  either  ratified  or  corrected  the  opinion  that  had  been 
formed.  During  the  period  that  I  held  the  office,  more  than  twelve 
thousand  patients  came  under  my  notice,  and  the  construction  of 
a  new  register  of  disease,  classified  on  the  plan  adopted  in  this  vo- 
lume, led  to  a  more  earnest  attention  to  methods  of  diagnosis. 

In  offering  to  those  now  engaged  in  study  the  observations  here 
embodied,  I  have  only  committed  to  writing  the  system  of  investi- 


IV  PEEP ACE. 

gation  which  it  became  my  habit  to  pursue;  and  if  it  lead  them  to 
a  more  familiar  acquaintance  with  disease,  and  a  better  understand- 
ing of  treatment,  my  time  will  not  have  been  misspent.  I  have  en- 
deavoured to  arrango  in  a  larger  type  the  general  and  more  im- 
portant considerations  on  which  diagnosis  is  based,  elaborating  the 
details,  and  enumerating  the  points  of  less  importance  in  type  of  a 
smaller  size.  It  seemed  desirable  that  my  younger  readers  should 
not  in  the  first  instance  be  perplexed  by  the  number  and  variety  of 
symptoms,  while  at  the  same  time  they  should  be  furnished  with  all 
particulars  on  any  subject  which  they  wished  to  study  more  closely. 
I  cannot  attempt  to  trace  back  to  their  source  all  the  suggestions 
received  from  the  writings  of  others,  and  from  oral  instruction,  or 
to  separate  such  suggestions  from  the  ideas  which  have  occurred  to 
myself  in  prosecuting  this  subject:  and  I  trust  that  it  will  be  under- 
stood that,  in  omitting  all  reference  to  authorities,  there  is  no  in- 
tention on  my  part  either  to  claim  the  merit  of  originality  or  to  ap- 
propriate unacknowledged  the  labours  of  others.  If  any  of  my  es- 
teemed friends  and  teachers  in  the  Profession  should  find  their  own 
ideas  or  expressions  repeated  in  this  volume,  it  is  only  because  these 
ideas  have  become  established  as  truths  in  my  own  mind,  and  the 
expressions  in  Which  they  are  conveyed  have  become  their  habitual 
and  almost  necessary  exponents.  That  such  a  manual  should  be 
free  from  faults,  the  utmost  stretch  of  self-satisfied  vanity  could 
never  lead  me  to  believe;  I  hope  that  they  will  be  found  to  be  errors 
of  omission  rather  than  of  commission, — that  in  the  main  the  prin- 
ciples will  be  admitted  by  all  to  be  true,  while  none  of  the  details 

are  calculated  to  mislead. 

A.  W.  B. 

Brtjton-street,  Berkeley-square, 
October,  1S57. 


Outline  of  the  Particulars  which  a  Clinical  Cleric  ought  to  attempt  to  enumerate 
in  the  History  of  each  Case  which  he  records. 

Address— Name— Age— Sex— Civil  state— Occupation— (iii  Females,  number  of 
children— date  of  last  pregnancy— menstrual  function.) 

History : — 

a.  Of  present  attack. 

b.  Of  previous  illness. 

Present  state: — 

• 

1.  General  symptoms: 

a.  Skin ;  as  to  heat  and  dryness. 

b.  Pulse ;  as  to  frequency,  force,  and  fulness. 

c.  Tongue;  as  to  coating  and  moisture. 

d.  Bowels  and  urine. 

e.  Appetite  and  thirst. 

2.  Appearance: 

a.  Size. 

b.  Aspect  and  expression. 

c.  Colour. 

3.  Position  or  posture: 

a.  In  bed. 

b.  Out  of  bed — Gait  and  manner. 

4.  Sensations. 

Survey  of  regions  and  organs:— 

1.  Innervation: 

a.  Brain. 

b.  Nerves. 

2.  Respiration. 

3.  Circulation : 

a.  Heart. 

b.  Blood-vessels. 

4.  Digestion: 

a.  Assimilation. 

b.  Excretion — Character  of  stools — Analysis  of  urine. 


TABLE  OF  CONTENTS. 


INTRODUCTION. 

The  Province  of  Diagnosis — Symptoms,  Various  and  Complex — Error  of  Pathog- 
nomonic Signs — of  Neglect  of  Diagnosis — Object  of  this  Treatise — True  Basis 
of  Diagnosis — in  Correct  Evidence  and  Knowledge  of  Disease— Compound 
Causes— Relation  to  the  Theory  of  Disease pp.  17 — 24 

CHAPTER  I. 

METHOD    OF    DIAGNOSIS. 

History  of  Case — Narrative  of  previous  Symptoms — its  Value  and  Fallacies — Ar- 
rangement of  existing  Phenomena — Division  into  General,  Local;  Objective, 
Subjective;  Signs  and  Symptoms — Plan  of  carrying  on  the  Investigation — First 
Deviation  from  H^illh — General  State  of  the  Patient — Examination  of  Or- 
gans— Classificati<wof  Diseases  necessary  for  Diagnosis — Table  of  Diseases. 

pp.  25 — 31 

CHAPTER  II. 

DURATION    AND    SEQUENCE    OF    PHENOMENA. 

Important  Results  of  this  Inquiry— Dividing  Diseases  into  Acute  and  Chronic — 
Long  Ailment  modifies  both  Diagnosis  and  Treatment — Pain  in  reference  to 
Duration — Order  of  Sequence  traces  Disease  back  to  its  Origin — The  Estab- 
lished Course  of  Disease    in  its  bearing  on  Diagnosis     ....      pp.  32 — 34 

CHAPTER  III. 

GENERAL  CONDITION  OF  THE  PATIENT. 

Objective  and  Subjective  Phenomena— Divided  into,  1,  General  Symptoms;  (a) 
Temperature  and  Dryness  of  Skin;  (6)  Fulness  and  Quickness  of  Pulse;  (c) 
Appearance  of  Tongue ;  (d)  State  of  Bowels  and  Kidneys  ;  (e)  Desire  for  Food 
and  Drink — 2,  General  Appearance;  (a)  Changes  of  Size;  (b)  Aspect  and  Ex- 
pression; (c)  Changes  of  Colour — 3,  Position  or  Posture;  (a)  in  bed:  (6)  out  of 
bed,  gait — 4,  The  Sensations  of  the  Patient — What  he  has  to  complain  of— 
Particular  Signs  from  the  foregoing  Sources pp-  35 — 47 

CHAPTER  IV. 

FEBRILE    DISEASES. 

Local  Signs  chiefly  Negative — General  Symptoms  of  Febrile  State. 

Div.  I. — Fevers.— \  1,  Continued  Fever — History  and  Symptoms — Classification — 
Epidemic — Endemic— Ephemeral— Varieties  of  Spotted  Rash — Complications 
— Cranial— Thoracic— Abdominal— §  2,  Remittent  Fever— Infantile  Remittent 
—\  3,  Influenza—?  4,  Epidemic  Cholera— its  Epidemic  Character— Symptoms 
— Relation  to  Diarrhoea. 

Div.  11. — Eruptive  Fevers— Measles — Scarlatina — Varioloid  Eruptions — Erysipe- 
las— Preliminary  Fever— its  Distinguishing  Symptoms — Specific  Characters  of 
the  Eruptions — Complications. 

Div.  III. — Intermittent  Fevers — Complete  Intermission — Regular — Quotidian, 
Tertian  and  Quartan  Agues— Irregular pp.  48 — 65 


viii  CONTENTS. 

(MIA ITER  V. 

RHETJMATI8M    AND    01 

ctive  Phenomena — Sensations. — \  1,  Acute  Rheumatism — Febrile  State — 
,.:ll  Svn"  ;ure  Cases— Distinctions  from  Gout  and  Secondary  De- 
posits—  Complications  —  \  2,  Sub-acute  Rheumatism  —  Fibrous — Synovial — 
amplications  -\  3,  .Muscular  Rheumatism — Lumbago — \  4,  Chronic  Rheuma- 
tism—its Characters— Simulated  by  Neuralgia — by  Disease  of  joints — Com- 
plicatioD  —  5,  Gout — Early  Symptoms — First  Attack — Subsequent  attacks — 
Qo  kse  of  Kidney — \  6,  Rheumatic  Gout — Distortion — Linger 
ing  Character pp.  66— 74 

CHAPTER  VI. 

DISEASES    OF    ADVENTITIOUS    ORIGIN'. 

Characteristics  of  the  Class.  _ 

DIY<  J, —  Poisoning. — \  1,  Common  Poisons — f/t)  Irritant — (b)  Narcotic — (c)  Ga- 
seous— (<0  Slow  Poisoning — \  2,  Animal  Virus — (<i)  Syphilis  and  Gonorrhoea 
—(b)  Hydrophobia— (c)  Glanders— \  3,  Colica   Pictonum— the  Blue  Line— 

TjGjid  PftlsVi 
DIV    il._Kntozoa. — \  1,  Echino-coccus   Hominis — \  2,  Intestinal  Worms — (a) 
Tapeworms — Taenia  Solium — Taenia  Lata — (b)  Lumbrici — (c)  Ascarides 

pp.  75 — S  1 

CHAPTER  VII. 

DISEASES    OF   UNCERTAIN   OR.   VARIABLE    SWT. 

Chiefly  to  be  regarded  as  Symptoms. 

]);v.  I. Dropsies. — I  1.  Anasarca  the  Type  of  General  Dropsy — {«)  Acute — with 

and  without  Albuminuria— (6)  Chronic— its  Causes — (c)  Local  Dropsy  or  (Ede- 
ma  §  2,  Ascites — Association  with  Anasarca — from  the  same  or  from  distinct 

catises — Detection  of  Fluid — Obscure  cases — (a)  Large  Ovarian  Cyst — (b) 
Peritoneal  Adhesions — Causes — Disease  of  Liver — Chronic  Peritonitis — Oc- 
clusion of  Veins. 

D,v.  n.  —  Hemorrhages.— \  1,  Epistaxis  — its  Causes  —  \  2,  Haemoptysis  —  (a) 
Spurious — (b)  Genuine — Distinguished  from  Ha?matemesis — Associated  with — 
(</)  Phthisis — (6)  Disease  of  Heart— (c)  Aneurism — (d)  Fungoid  Growth — \  3, 
Haematemesis — Characters — («)  from  Erosion  of  a  Vessel — (6)  from  Disease  of 
Liver  and  Spleen — Vicarious — (c)  from  Malignant  Disease — \  1,  Haematuria — 
(a)  from  a  Calculus — [b)  from  Disease  of  Bladder — (c)  Accompanying  Purpura 

rtf\  from  Disease  of  Kidney — §  5,  Intestinal  Hemorrhage — Characters  and 

Causes — §6,  Uterine  Hemorrhage — Distinguished  from  Menorrhagia — in  Health 
—in  Disease pp.85—'.) 

CHAPTER  VIII. 

THE   CHRONIC   BLOOD-AILMENTS. 

\  1,  Purpura  and  Scurvy — Distinguishing  Features  of  each — Associations  and 
Causes — \  2,  Anaemia — (a)  from  Hemorrhage — (?>)  from  Want  of  Nutriment 
\A  from  Imperfect  Assimilation — (<7)  from  Exhausting  Diseases— ^Causes  un- 
defined—3  3,  Chlorosis — its  definite  Relation  to  the  Uterus — Distinguished  from 
Amenorrhcea — \  4,  Aiuemic  Blood-murmurs — "Bruits"  in  general — Cardiac 
and  Arterial — Venous  Hum—?  5,  Cachaemia,  or  Cachexia — Pyaemia — its  pro- 
bable Cause  is  Phlebitis — Secondary  Deposits — in  Internal  Organs — in  the  Skin 
and  Cellular  Tissue pp.  100— 107 

CHAPTER   IX. 

DKPRAVED    CONSTITUTIONAL    STATES. 

I)tr.  I._ Scrofula  and  Tubercles.—?  1,  Scrofula— Chiefly  seen  in  Childhood— \  2, 
Tabes  Mlesenterica — \  3.  Phthisis — Acute  and  Chronic — General  Characters  of 
the  Acute  Form— its  Early  Stage— Symptoms  of  the  Chronic  Form— Suspicious 


CONTENTS.  IX 

Symptoms—?  4,  Tubercles  in  the  Peritoneum— associated  with  Chronic  Perito- 
nitis— \  5,  Tubercles  in  the  Brain. 
Div.  II.— Morbid  Growths— §  1,  Of  Local  Enlargements— from  Hypertrophy- 
Deposits  of  Fat— Presence  of  Serum— of  Blood— of  Lymph— of  Pus— §  2,  Of 
the  Locality  of  Tumours— Superficial— Deep-seated— their  History  and  Symp- 
toms—Relations—Tumours  on  the  general  Surface— on  the  Head— in  the  Neck 
—on  the  Chest— Abscess  from  Empyema— Aneurism— Morbid  Growth— in  the 
Abdomen — connected  with  various  Organs — Accumulations  of  Faeces— Peri- 
toneal Abscess— §  3,  Of  the  Nature  of  Tumours— Cystic  Growths— Fungoid 
or  Encephaloid  Cancer — Scirrhus — Colloid  Cancer — Osseous  Growths — the  dis- 
tinguishing Characters  of  each      pp.  108— 121 

CHAPTER  X. 

THE  QUASI-NERVOUS   DISEASES. 

I  1,  Hysteria— Subjective  Phenomena— Evidence  almost  entirely  negative — His- 
tory and  Symptoms— Simulation  of  other  Diseases— Globus  Hystericus — Hyste- 
rical Fits — h  2,  Chorea  and  Tetanus — The  Muscular  Movements  in  each — Con- 
ditions of  System— Causes  and  Associations—  $  3,  Delirium  Tremens— The 
Nervous  Element— History— State  of  Pulse,  Tongue,  and  Skin— Alliance  to 
Mental  Disease PP-  122— 12G 

CHAPTER   XL 

GENERAL   EXAMINATION    OF    REGIONS   AND    ORGANS. 

Disease  often  a  Compound  Phenomenon — All  Organs  ought  to  be  examined — 
Negative  as  well  as  Positive  Results  stated — Examination  of  Brain  and  Nerves 
— of  Chest— of  Digestive  Organs— of  Uterine  Functions— Appearance  of  Skin 

pp.  127—1.29 

CHAPTER  XII. 

SEMEIOLOGY   OF   DISEASES   OF   THE   BRAIN. 

Causes  of  Obscurity— Mental  Faculties  confused— History  imperfect— Pathology 
little  known. 

DIV.  L— Svmptoms  derived  from  the  Mental  Functions.— 5  1,  Coma  or  Insensi- 
bility— (a)  from  a  Fall— (b)  an  Apoplectic  Seizure— (c)  from  Poisoning— [d) 
from  Effusion  of  Serum— §  2,  Stupor,  or  Unconsciousness— (a)  after  Epilepsy 
(!>)  Transient  Apoplexy— (c)  from  Poison — [d)  in  Disease  of  Kidney—*  3,  In- 
somnia — $  4,  Delirium— with  or  without  Unconsciousness — is  not  Evidence  of 
Inflammation— (a)  Delirium  of  Fever— (6)  of  Delirium  Tremens— (r)  of  In- 
flammatory Fever— (d)  of  Rheumatism  and  Erysipelas— (e)  of  Scrofulous  In- 
flammation— (f)  of  Simple  Inflammation — (#)  of  Mania— the  general  Characters 
of  Insanity — its  Distinguishing  Features. 

DIV-.  II.— Symptoms  from  Nervous  Sensibility.— §  1,  General  Alterations  in  Sen- 
sibility—Increased— Diminished— Perverted— $  2,  Alterations  in  the  Sense  of 
Sight— (a)  Difference  in  Size  of  Pupils— (&)  Contracted  Pupil— (c)  Dilated— 
(d)  Perversions  of  Vision— §  3,  Alterations  in  Hearing— (a)  Recent  Deafness 
—(b)  of  Long  standing— (c)  Intolerance  of  Sound— (d)  Noises—  $  4,  Special  Al- 
terations of  Sensibility — Local  Pain — Headache  and  Giddiness. 

P)jV.  III.— Alterations  in  Muscular  Movement.— §  1,  Spasmodic  Action— Subsnlt.ua 
—Convulsion— Spasm— $  2,  Paralysis— Relative  Value  of  Different  Forms— 
Ptosis— Strabismus PP-  130—148 

CHAPTER  XIII. 

DISEASES    OF    THE    BRAIN. 

History— Condition  of  other  Organs — Acute  and  Chronic  Disease— Antecedent 
States.—?  1,  Scrofulous  or  Tubercular  Inflammation— Its  Pathology — In  In- 
fauCy — its  Early  Stage — distinguished  from  Fever— from  Gastric  Disorder — its 
Advanced  Stage— The  Hydrencephaloid  Disease— in  Adults— associated  with 
Early  Phthisis— with  Advanced   Phthisis— its   Characters— Tubercles   in   the 


X  CONTENTS. 

Braia  { 2,  Simple  Inflammation — Antecedents — Characters — Variety  of  Symp- 
toms— Locality  of  the  inflammation— Sequence  of  Phenomena — #  :?,  Chronic 
Disease  Resembles  Functional  Disturbance— History — Chronic  Inflamma- 
tion -Symptoms  —  Subjective— Objective — #  4,  Apoplexy — Characters  of  the 
Fit —  History — Partial  Coma — Convulsion — Serous  Apoplexy — Distinguishing 
laracters— Associations — #  5,  Epilepsy — Convulsions — in  Childhood — Perio- 
dicity  of  Epilepsy  -its  Characters — Hysterical  Epilepsy — §  6,  Functional  Dis- 
turbance—With  Disturbed  Circulation — with  Disorder  of  Digestion — Nervous 
States  -Characters  of  the  Class — Mental  Functions — Sensations — Spasm — its 
Associations — with    Circulation — Digestion — with    Nervous    Excitement   pp. 

149—167 

CHAPTER  XIV. 

DISEASES    OF    THE    SPINAL   CORD. 

Inflammation  rare  as  an  Idiopathic  Disease — its  History  and  Symptoms — Con- 
nexion with   Caries — Spinal  Irritation — Chronic  Disease     .     .     pp.  1C8 — 170 

CHAPTER  XV. 

PARALYSIS. 

Loss  of  Sensation — of  Power  of  Motion — Incomplete  Paralysis — Power  of  Re- 
sistance— Simulated  by  Hysteria. —  $  1,  Hemiplegia — Definition — Modes  of  In- 
cursion— its  Central  Origin — Causes  and  Complications — $  2,  Paraplegia — its 
Causes — («)  Atrophy — (b)  Injury  or  Disease  of  Bone — (c)  Inflammation  of  Cord 
— (</)  Pressure  of  a  Tumour — (r)  Spinal  Apoplexy — (/)  General  Paralysis — 
[g)  Paralysis  Agitans — its  Simulation — §  3,  Local  Paralysis — Meaning  of  this 
Term — Nervous — in  Cranial  Nerves — in  Nerves  of  Extremities — Muscular — 
Drop-wrist — Fatty   Degeneration pp.   171 — 180 

CHAPTER  XVI. 

NEURALGIA. 

Its  place  in  Classification — Distinguished  from  Pain — Inflammation — General 
Pain — Local  Pain — Irritation — Neuralgia  proper. —  $  1,  Tic-Douloureux — §  2, 
Hemicrania — $  3,  Sciatica — $  4.  Angina  Pectoris — Distinguished  from  Dys- 
peptic Attacks — $  5,  Spinal  Neuralgia        .    • pp.  181 — 187 

CHAPTER  XVII. 

EXAMINATION    OF    THE    CHEST. 

Importance  of  Correct  Knowledge — its  Sources. — §  1,  History  and  general  Symp- 
toms— Duration— Acute  and  Chronic  Disease — Previous  Illness — Present 
State — Indications  ol  Fever — of  Emaciation — Sensations — Pain — Character  of 
Breathing — of  Cough — of  Expectoration — §  2,  Physical  Signs — Sources  of  In- 
formation— (")  External  Appearances — Form  and  Movement. — (//)  Percussion 
— its  Teaching — Sources  of  Fallacy — («)  Auscultation — its  Application — False 
Nomenclature — Modifications  of  Breath  and  Voice-sounds — Superadded  Sounds 
— How  Deductions  are  to  be  drawn pp.  188 — 197 

CHAPTER  XVIII. 

MODIFICATIONS    OF    NORMAL    BREATH    AND  VOICE-SOUND,  AND    OF    PERCUSSION    RESO- 
NANCE. 

Div.  I. — The  Clavicular  Region. — $  1,  Breath  and  Voice-Sounds  with  dulness 
under  one  Clavicle — (a)  Breathing  louder  on  Duller  Side — (b)  Breathing 
weaker  on  Duller  Side — Varieties  of  each — §  2,  with  Excessive  Resonance — 
(a)  Breathing  louder  on  more  Resonant  Side — (is)  Breathing  weaker  on  more 
Resonant  Side — Varieties  of  each — \  3,  with  Difference  on  Percussion  slightly 
marked — (a)  Breathing  louder  on  Duller  Side — Varieties — (n)  Breathing 
weaker  on  Duller  Side — $  4,  with  no  Perceptible  Difference — (a)  Apices  healthy 
— (u)  Both  Emphysematous — (c)  Both  Duller   than  Natural — Varieties — (d) 


CONTENTS.  XI 

Difference  existing,  but  not  detected — Rules  for  ascertaining  Early  Changes  in 
the  Lung-Structure. 

Div.  II. — The  Posterior  and  Lateral  Regions. — $  1,  Breath  and  Voice-Sounds, 
with  marked  Dulness  on  one  Side — (a)  Xo  Breathing  at  Base— (h)  Harsh 
Breathing  at  Lower  Part — (c\  Breathing  generally  weak  on  Dull  Side — $  2, 
■with  Excessive  Resonance — (a)  Amphoric  Breathing — (b)  Breathing  Inaudible 
— {()  Emphysema — $  '■'>.  with  Difference  on  Percussion  slightly  marked — (a) 
Slight  Consolidation — (b)  Slight  Emphysema — (<  )  Early  Stage  of  Inflammation 
— (i>)  Acute  Tuberculosis — $  4,  with  no  Perceptible  Difference — (a)  Resonance 
Natural— (a)  in  Phthisis — (b)  in  Bronchitis — («)  Both  Sides  unusually  Reso- 
nant—  (c)  Both  somewhat  Dull—  (u)  Difference  existing,  but  not  perceived — 
Rules  applicable  in  such  Cases. 

S  mary. — $  1,  Condensation  of  Lung-tissue — Carnification — Hepatization — Tu- 
berculization— their  different  Characters — §  2,  Expansion  of  Lung-tissue — Em- 
physema—  $  3,  Condition  of  the  Pleura pp.  198 — 214 

CHAPTER  XIX. 

SUPERADDED    SOUN'DS  IX    THEIR  RELATION'    TO    ALTERED    BREATH  AXD  VOICE-SOUNDS. 

Classification  of  Sounds — 4  L  Interrupted  Sounds — (a)  Crepitation — (Ij)  Moist 
S  mnds — (<")  Gurgling — ('/)  Metallic  Tinkling — §  2,  Continuous  Sounds — (a) 
Sonorous  and  Sibilant  Sounds — (b)  Friction — (c)  Crumpling — (d)  Creaking. 

Div.  I. — The  Clavicular  Region. — $  1,  With  marked  Dulness  on  one  Side — (a) 
from  Condensation — (k)  from  Pleuritic  Effusion — (c)  from  a  Tumour — $  2, 
with  Excessive  Resonance — (a)  Pneumo-lhorax — (b)  Emphysema — $  3,  with 
less  marked  Difference  on  Percussion — (a)  Tubercular  Consolidation — (b)  Em- 
physema—  $  4,  With  no  Perceptible  Difference — (a)  Apices  healthy — (b)  Both 
Emphysematous  —  (c)  Equal  Dulness — (n)  Difference  existing,  but  not  de- 
tected—The more  important  Sounds  in  such  Cases. 

Div.  II. — The  Posterior  and  Lateral  Regions. — $  1,  With  marked  Dulness  on 
one  side — (a)  Simple  Serous  Effusion — (b)  Effusion  with  Pneumonia — (c) 
Exudation  of  Lymph — §  2.  with  excessive  Resonance — (a)  Pneumothorax — 
(b)  Emphysema — $  3,  with  less  marked  Difference  on  Percussion — (a)  Caused 
by  Consolidation — its  various  Forms — (b)  by  increased  Resonance — (c)  by  a 
Tumour — \  4,  with  no  Perceptible  Difference — (a)  Both  Sides  Natural — (b) 
Both  Resonant — (c)  Both  Slightly  Dull — (n)  Difference  existing,  but  not  de- 
tected— Various  circumstances  causing  this  effect. 

Summary. —  The  Real  Teaching  of  Superadded  Sounds — the  Interrupted — the  Con- 
tinuous— heard  at  the  Apex  do  not  necessarily  indicate  Phthisis  .  pp.  215 — 231 

CHAPTER  XX. 

DISEASES    OF    THE    RESPIRATORY    ORGANS. 

\  1,  Laryngitis — Acute  and  Chronic — CEdema  of  the  Glottis— Varieties — to  be 
distinguished  from  Pressure  on  the  Trachea — §  2,  Tracheitis,  or  Croup — Crow- 
ing Inspiration — General  Characters  of  Croup — -Distinguishing  Characters  of 
False  Croup — $  3,  Pneumonia — its  History  and  Symptoms — its  Auscultatory 
Phenomena — in  the  Advanced  Stage— in  the  Early  Stage — Inflammation  of 
the  Upper  Lobe — Abscess — Gangrene — Chronic  Pneumonia — Complications — 
I  4.  Pleurisy — its  Early  Stage — its  Advanced  Stage— Auscultatory  Signs — Com- 
plication with  Pneumonia — Passive  Effusion — Associations— Causes  of  Pieurisy 
— Pleuiodynia — $  5,  Pneumo-thorax — History — Symptoms — Physical  Signs — 
the  Presence  of  Fluid— Metallic  Tinkling — ^uccussiou — $  6,  Bronchitis — Acute 
— Affects  both  Lungs  alike — Resemblance  tolnfluenza — Chronic — Auscultatory 
Phenomena — Occasional  Resemblance  to  Phthisis — Bronehorrhoea — $  7,  Em- 
physema—its Characters — with  Bronchitis — without  Bronchitis — its  Slighter 
Form — its  Aggravated  Form — $  8,  Asthma — its  History — Complication  with 
Emphysema — distinguished  from  it. — Hay  Asthma— §  9,  Phthisis  Pulmonalis — 
its  Hist  ry — General  Symptoms — their  Relative  Importance — Auscultatorj  Signs 
in  the  Early  Stage — their  Real  Meaning — in  the  Advanced  Stages — Fallacies 


xii  CONTENTS. 

— Relations  of  Superadded  Sounds  to  Tubercular  Deposit— tbeii  Rational  Ex- 
position—Liability to  attack  both  Lungs— Complication  with  Bronchitis— with 
pleurisy— with  Meningitis —  i  10,  Tumours — either  Aneurism  or  Morbid  Growth 

the  Auscultatory  Phenomena  to  which  each  gives  riee— G( 

I,1;  Circulation— f  U»  Hooping  Cough— il  ptoms— Sour<  Fal- 

lacy -$  12,  Diseases  of  the  Lungs  in  Childhood— Importance  oi  History  and 
General   Symptoms— Inflammation — Bronchitis— Tubercles     .    pp.  232—265 

CHAPTER  xx  r. 

EXAMINATION'    OF    THE     HEART. 

History  and  Symptoms— Changes  independent  of  Disease — Special  Signs. 

Div.  I.— Evidence  of  Alteration  of  Size— Change  of  Position— Increased  Impulse 
—Irregular  Actions-Extended  DulnesB— Abnormal  Sounds— Mutual  Relations 
with  Irregularity — with  Increased  Action. 

]),v.  I[. Auscultatory  Phenomena — Murmurs  and  Sounds. — \  1,  Modifications  of 

Normal  Sounds— in  Intensity— in  Distinctness— in  Rhythm— Reduplication— 
their  Relative  Importance—?.  'J,  Friction— its  Distinguishing  Features— Position 
—Characters— Rhythm — its  Indications— Friction  in  the  Pleura — §  3, Endocar- 
dial Murmurs— General  Characters— Mode  of  Determining  their  time  and  Place 
—(a.)  Diastolic— Aortic— Mitral— Characters  of  each— (b)  Systolic  Murmurs 
—(1)  at  the  Apex— Mitral— Tricuspid— Blood-Sound— (2)  at  the  Base— Cha- 
racters of  a  Valvular  Sound— Aortic— Pulmonic— Blood-Sound— Rules  for  Di- 
agnosis      pp.266— 2/9 

CHAPTER  XXII. 

DISEASES   OF   TI1E    HEART. 

History  and  Symptoms— Acute  and  Chronic  Disease— their  Commencement  often 
Obscure. S  1,  Pericarditis — its  Signs  and  Symptoms — Complications — Trust- 
worthy Indications — h  2,  Endocarditis— is  not  proved  by  the  Existence  of  a 
Murnmr— it3  Signs  and  Symptoms — Sources  of  Fallacy — the  Origin  of  Cardiac 
Inflammation  in  Rheumatic  Fever— Pericarditis— Endocarditis— Causes  of  Ob- 
scurity—Reliable Indications— Fallacies— §  3,  Hypertrophy— its  Indications- 
its  Causes— §  1,  Dilatation— its  Signs  and  Symptoms— the  Flabby  or  Fatty 
Heart — Association  with  Hypertrophy — \  4,  Valvular  Lesion—its  History — 
with  and  without  Bruit— Evidence  of  its  Existence— Mechanism  of  the  Circula- 
tion—Circuit of  the  Blood — Production  of  Murmurs— Evidence  of  Valvular 
Lesion— ('!)  from  the  Pulse— (b)  from  Existence  of  Hypertrophy— (c)  from 
the  Appearance  of  the  Patient— Obscure  Cases— Causes  of  Disease  of  the  H. 
— its  Results — its  Associations ;    PP-  280 — 292 

CHAPTER  XXIII. 

DISEASES  OF  THE  BLOOD-VESSELS. 

£),v  l._Diseases  of  the  Arteries— Arteritis — Aneurism. — \  1,  Superficial  Aneu- 
rism—its Diagnosis— \  2,  Thoracic  Aneurism— Early  Symptoms—  Dj  5] 
Jogging  Sound— Advanced  Stage— Pulsation— f  3,  Abdominal  Aneurism— Diffi- 
culty of  Diagnosis — Reliable  Indications. 

Div.  II.—  Diseases  of  veins— Phlebitis— \  1,  Pyccmia— the  consequence  of  Suppu- 
rative Phlebitis— §  2,  Phlegmasia   Dolens— its  Peculiarities— Inflamed  V- 
and  CEdema— \  3,  Capillary  Phlebitis pp.  293—2   - 

CHAPTER  XXIV. 

DISEASES  OF  THE  MOUTH  AND  PHARYNX. 

Their  Associating  with  Diseases  of  the  Larynx— their  Commencement.—?  1,  Of 
the  Mouth— Glossitis— Ulceration  and  Aphthae— Can crum  Oris—  k  2,  Oi  the 
Fauces— (a)  Quinsy— Sore  throat— (6)  Enlarged  Tonsils— the  Voice  and  Cough 
_(,)  Ulceration  after  an  Acute  Attack— Scrofulous— Syphilitic—  \  3,  Of  the 
Glands— Mumps— Cervical  Glands PP-  2"     303 


CONTENTS.  XU1 

CHAPTER  XXV. 

EXAMINATION  OF  THE  ABDOMEN. 

General  Relations  of  Abdominal  Disease  —  History  —  General  Symptoms  — 
Effects  upon  the  Health — Sensations  often  referred  to  other  Regions — Actual 
Examination — (1)  of  Outlets — (2)  of  Excreta — (3)  of  Abdomen  itself — (a)  by 
Inspection — (6)  by  Palpation — (c)  by  Percussion pp.  304 — 307 

CHAPTER  XXVI. 

DISEASES  OF  THE  OESOPHAGUS  AXD  STOMACH. 

Uncertainty  of  Symptoms — Sources  of  Information — Sympathetic  affections  of 
other  Organs. —  §  1,  The  Oesophagus  and  Cardiac  End  of  the  Stomach — Stric- 
ture— Spasm — $  2,  Organic  Lesions  of  the  Stomach — (a)  Stricture  of  the  py- 
lorus—  Scirrhus  —  Simple  Thickening  —  their  Diagnosis — (6)  Ulceration  — 
Hemorrhage — (c)  Gastritis — its  Rarity — (d)  Dilatation — its  Causes — its  Symp- 
toms—  §  3,  Functional  Disorders  of  the  Stomach — their  common  Occurrence — 
Division  —  (a)  Irritability  —  its  Indications  —  (6)  Distention — its  Causes — (c) 
Faulty  Secretion — (1)  in  Hyperemia — (2)  in  Anaemia — (3)  Specific  Forms — 
(1)  Undefined  Forms — Associations  of  Dyspepsia    ....        pp.  308 — 318 

CHAPTER  XXVII. 

DISEASES  OF  THE  INTESTINAL  CAXAL. 

Primary  Division — General  Relations  of  Inflammation. 

Div.  I.—  Diseases  attended  with  Constipation. — $  1,  Constipation — its  History — 
Causes — Results — §  2,  Enteritis — with  Previous  Obstruction — Simple  Inflamma- 
tion— §  3,  Ileus  or  Intus-susception — its  Characters — with  or  without  Obstruct- 
ing Cause — Closure  from  Bands  of  Adhesion — §  4,  Obstruction — its  general 
Signification — Slow  Progress — Diminished  Calibre — Excessive  Distention — 
Position  of  the  Obstruction. 

Div.  II. — Diseases  attended  with  Relaxation. — §  1,  Diarrhoea — (a)  without  Febrile 
Symptoms — Varieties — (b)  with  General  Symptoms  due  to  other  Diseases — (c) 
■with  Febrile  Symptoms — especially  in  Childhood— (d)  Chronic  Diarrhoea — §  2, 
Dysentery — Acute — Chronic — $  3,  Ulceration — Hemorrhage — pus. 

Div.  111. —  Diseases  attended  with  altered  Secretion  —  $  1,  Disordered  Bowels — 
('/)  in  Childhood — (6)  Special  Alterations — $  2,  Tympanites — Sources  of  Er- 
ror      pp.  319—329 

CHAPTER  XXVIII. 

DISEASES  OF  THE  PERITONEUM. 

§  1,  Acute  peritonitis— (a)  Traumatic — from  Rupture  of  some  Viscus — after  in- 
jury—  (b)  Puerperal — Association  with  Erysipelas — (c)  idiopathic — its  very 
marked  Characters — (</)  Partial  Peritonitis — excited  by  Ulceration  of  Stomach 
or  Bowels — Suppuration — §  2,  Chronic  Peritonitis — (a)  after  an  Acute  Attack 
— Association  with  Ascites — (b)  Tubercular  or  Cancerous — $  3,  Morbid  Growths 
in  the  Peritoneum— General  Appearance — Symptoms     .     .     .      pp.  330 — 337 

CHAPTER  XXIX. 

DISEASES  OF  THE  LIVER,  SPLEEN,  AXD  PANCREAS. 

Div.  I. — Diseases  of  the  Liver — Obscurity  of  Symptoms — Biliousness — §  1,  In- 
flammation— Congestion — Abscess — after  Hepatitis — Suppurating  Cyst — §  2, 
Enlargement — Interstitial  Deposit — Morbid  Growth — $  3,  Cirrhosis — associated 
with  Ascites — Yellow  Atrophy — Scirrhus — $  4,  Jaundice  —  Emotional — with 
Contraction — with  Enlargement — with  Disease  of  Heart — Functional  Disorders 
of  Liver — §  5,  Gall-stones — their  Diagnosis — Diseases  with  which  they  may  be 
confounded. 

Div.  II. — Diseases  of  Spleen — Change  of  Structure — Enlargement. 

Div.  III. — Disease  of  the  Pancreas — Scirrhus  .         .         .         pp.  338 — 347 


XIV  CONTENTS. 

CIIAPTER   XXX. 

EXAMINATION    OP   THE    URINE. 

isiderations — Analysis — Ordinary  Tests. — jj  1,  Acidity  and  Alkal 
cence — Fixed  Alkali— Volatile  Alkali — \  2,  Specific  Gravity — \  3,  G<  nefal  Ap- 
pearance— (•')  Tr  loured — Limpid — Coloured  with  Bile — 
(/,  ie — White — Dark-colouri-d — ■ |  I.  Sediments — (a)  Chemical  Relations 
— (1)  Soluble  by  Heal  —  (2) — Insoluble— (3)  8oluble  in  Nitric  Acid— not  in 
Hydrochloric — (4)  Soluble  in  Liquor  Potassse — (5)  Partly  soluble  by  Heat — 

|  Microscopical  AppearanceB — Organic  Bodies— (1)  Blood-globules — {'!)  I 
and  Mucus-globules— (3)   Epithelium— (4)  Tubular  Casts — (5) — Vibriones— 

oa — Crystalline   Substances— (I)   Oxalate  of  Lime— (2)   0 
Acid— (3)  Triple  Phosphate— §  5,  The  Urine  free  iron.  Deposit— (a-)  Albumen 
—Test  by  Acid— by  Heat — Sources  of  Fallacy — (6)  Sugar— Test  by  Liq 
Potassae — by  Salts  of  Copper — Specific  Gravity — (c)  Urea — Table  of  Chemi 
Relations •."...        pp.  348—3  12 

CHAPTER   XXXI. 

DISEASES    OF    THE    URINARY   ORG* 

$  1,  Nephritis  and  Nephralgia — after  Exposure — from  Scarlatina — from  Calculus 
— Symptoms — Diseases  with  which  they  may  be  confounded — $  2,  Abscess- 
Modes  of  Discbarge — in  the  Loins — by  the  Bowel — with  the  Urine — distin- 
guished from  Catarrh  of  the  Bladder — \  3,  Ischuria — Distinguished  from  Re- 
tention— its  Causes — k  1.  Albuminuria — its  Meaning — Origin — Symptoms — 
Characters  of  the  Urine  indicating  I  of  the  Kidney — low  Specific  Gravity 

— abundant  Pr  of  Albumen — Permanent  Albuminuria — with  or  wilh- 

out  Dropsy — Transient  Albuminuria — Hematuria — $  5,  Diuresis — $  6,  Cystitis 
— from  Distention — from  Calculus — Catarrh — Ropy  Mucus — $  7,  Diabetes — 
General  Symptoms — §  8,  Disordered  Function — Excess  or  Deficiency  of  Water 
— Deposits — Uric  Acid — Phosphates — Alkalescence  and  Acidity — Urea — Oxa- 
late of  Lime — Relations  of  Disease  of  the  Kidney  .         .         pp.363 — o."> 

CHAPTER  XXXII. 

DISEASES    OF    THE    OVARIES. 

General  Considerations — Ovaritis — Obscure  Origin  of  Disease  of  the  0 varies — 
Associations.— $  1,  Ovarian  Dropsy — Resemblance  to  Ascites — Distinguishn: i 
Characters — Principles  of  Diagnosis — \  -.  Tumours — Varieties — known  by  their 
Pelvic  Attachments  —  distinguished  from  Pregnancy — Digital  Examination 

pp.  o"(i — 3S0 

CHAPTER   XXXIII. 

DISEASES    OF   THE   UTERUS. 

\  1,  Amenorrhea — distinguished  from  Chlorosis — Dependent  on  Local  Causes— 
Irregular  and  Painful  Menstruation — \  2,  Menorrhagia — distinguished  from 
Hemorrhage — S  3,  Leucorrhcea — distinguished  from  Gonorrhoea — Vaginitis — 

k   4,  Tumours — Fibrous — Polypous— §  5,  Prolapsus — Malposition — Prolapsus 
of  Vagina — h  6,  Congestion  and  Ulceration — their  limited  Existence — Can 
—  \  1,  Cancer — its  Advanced  Stage — its  Early  Stage      .         .         pp. 381- 

CIIAPTER   XXXIV. 

DISEASES    OF    THE     RONES,    JOINTS,    AND    MUSCLES. 

DJVi  7 — Diseases  of  Bones  and  Joints — their  Constitutional  Character — Periosti- 
tis— Rachitis — Mollities — Fragilitas. 
Div.  II. — Diseases  of  Muscles — Paralysis — Fatty  Degeneration.         pp.  388—390 


CONTENTS.  XV 

CHAPTER   XXXV. 

DISEASES    OF   THE   SKIN   AND    CELLULAR   TISSUE. 

General  Principles  of  Diagnosis — the  Early  Stage. — $  1,  Erythema — Urticaria 

Roseola — $  2,  Papular  Eruptions — Lichen  and  Prurigo — Varieties — $  3,  Squa- 
mous Eruptions — Ichthyosis — Lepra — Psoriasis  —  Pityriasis — §  4,  Vesicular 
Eruptions— Eczema — Varieties— Herpes— Special  Forms— Scabies— the  Aca- 
rus — $  5,  Pustular  Eruptions  —  Impetigo — Ecthyma — Acne  —  Sycosis — $  (!, 
Pemphigus— Pompholyx— Rupia— §  7,  Vegetable  Parasites-— Favus — Porrigo 
Decalvans — Pityriasis  versicolor — $  8,  Tubercle  of  the  Skin — Elephantiasis°of 
the  Greeks — $  9,  Syphilitic  Eruptions — the  Copper-colour — Analogy  to  other 
Cutaneous  Diseases — Changes  of  Colour  generally — $  10,  Lupus — Scrofulous 
Ulcer — Cancer  of  the  Skin— Cancrum  Oris—  $  11,  Endemial  Diseases  of  the  Skin 

— $   12,  Cellular  Inflammation — its  Relation  to  Erysipelas — to  Phlebitis to 

Secondary  Suppuration— General  Relations  of  Diseases  of  the  Skin  as  aids  to 
Diagnosis pp.  391—407 

lNDEX pp.  409— 423 


MEDICAL  DIAGNOSIS. 


INTRODUCTION. 

The  Province  of  Diagnosis — its  Uses  and  Abuses — its  Neglect — 
its  Relation  to  the  Theory  of  Disease. 

The  ultimate  object  of  study  in  all  departments  of  medicine — 
the  object  -which  must  ever  be  kept  in  view  alike  by  teacher  and 
pupil — is  the  relief  of  the  patient  by  the  successful  treatment  of 
disease.  To  this  end  the  properties  of  various  remedial  agents  are 
taught  in  Materia  Medica,  as  they  possess  the  power  of  neutralizing 
or  eliminating  poisons,  of  counteracting  morbid  action  in  its  progress 
or  modifying  its  results,  and  of  aiding  and  sustaining  the  powers  of 
life,  -when  those  wonderful  laws  of  our  economy  come  into  operation, 
by  which  the  destructive  agency  of  noxious  influences  is  combated, 
and  the  useless  and  effete  or  injured  tissues  are  extruded  from  the 
body.  To  the  same  end  the  student  must  acquire  a  knowledge  of 
the  various  structures  of  the  body  and  the  functions  of  its  organs 
in  health,  as  well  as  the  pathological  changes  in  solids  and  fluids, 
which  become  the  subjects  of  anatomical  research,  and  perversions 
of  healthy  function  which  may  be  traced  at  the  bedside  in  the  pro- 
gress of  disease:  these  belong  to  the  domain  of  Physiology  and 
Pathology.  The  theory  of  disease,  again,  combines,  by  the  aid  of 
experience,  the  perversion  of  function  with  the  change  of  structure, 
deducing  the  symptoms  observed  as  a  necessary  sequence  from  the 
disturbance  of  the  laws  of  health  to  which  such  changes  must  give 
rise;  but  it  also  teaches  us  that  there  are  other  and  more  hidden  ele- 
ments of  disease,  stamped  in  their  operation  on  the  human  frame, 
with  characters  no  less  marked  and  distinct,  which  have  yet  evaded 
our  most  diligent  search.  This  department  divides  itself  into  two 
branches:  it  points  out  the  alliances  and  differences  between  various 
forms  of  disease  and  the  prominent  features  by  which  they  are 
characterized,  and  to  this  the  name  of  Nosology  has  been  applied; 
while  under  the  name  of  Semeiology  it  especially  treats  of  the 
symptoms  of  diseased  action  which  each  organ  or  region  of  the  body 
is  capable  of  manifesting.  It  is  the  province  of  Diagnosis  to  com- 
bine together  these  various  lessons,  and  by  the  application  of  the 
symptomatology  of  disease  in  general  to  any  particular  case,  to 
arrive  at  a  just  conclusion  regarding  its  true  nature  and  pathology: 
and  though  it  does  not  enter  directly  on  the  question  of  treatment, 


o 
9 


18  INTRODUCTION. 

it  has  regard  to  all  those  indications  on  which  it  ought  to  be  based. 
In  the  present  imperfect  condition  of  the  science  of  medicine,  too 
much  importance  can  scarcely  be  assigned  to  the  study  of  diagnosis, 
which,  in  its  higher  and  more  intricate  departments,  by  separating 
the  known  from  the  unknown  in  our  experience,  may  yet  point  out 
new  relations  between  morbid  phenomena  and  structural  change ; 
and  by  enabling  us  to  discriminate  the  finer  shades  of  difference 
which  distinguish  various  forms  of  allied  diseases,  must  lead  to  a 
more  perfect  classification.  Upon  the  basis  of  such  trustworthy 
generalizations,  we  may  hope  ultimately  to  arrive  at  more  perfect 
knowledge  of  the  causes  which  operate  in  the  production  of  each 
by  successive  elimination  of  those  that  are  proved  not  to  be  essen- 
tial, or,  as  they  may  be  called,  efficient  causes. 

But  on  this  question  we  are  not  to  enter.  Our  endeavour  must 
be  limited  to  laying  down  rules  by  which  the  student  may  be  able 
to  recognise  at  the  bedside  the  diseases  which  he  has  been  already 
taught  in  the  schools.  And  however  captivating  the  study  of  diag- 
nosis must  be  to  every  thoughtful  mind,  dealing  as  it  does  with  facts 
which  can  be  more  readily  appreciated  than  those  which  result  from 
the  action  of  remedies ;  however  gratifying  to  the  observer  to  call 
into  legitimate  exercise  the  highest  mental  functions,  and  to  be 
enabled  to  pronounce  a  judgment  upon  the  evidence  presented  to 
him,  which  subsequent  events  shall  prove  to  have  been  correct,  it 
must  still  be  remembered  that  this  is  but  a  means  to  an  end.  When 
elevated  out  of  its  true  place,  it  only  leads  to  the  "mddecine  ex- 
pectante;"  which,  boasting  of  its  knowledge  of  disease,  either  leaves 
the  patient  to  die  unrelieved  or  to  struggle  unassisted  through  his 
malady;  or  it  raises  the  practitioner  into  a  position  of  self-satisfied 
vanity,  which,  pretending  to  a  kind  of  omniscience,  causes  him  to 
overlook  any  fact  or  argument  opposed  to  his  conclusion,  until  death 
reveal  how  great  and  how  fatal  was  the  error.  When  neglected  or 
despised,  it  produces  that  trifling  treatment  of  symptoms  arising  in 
the  course  of  a  disease,  when  the  more  deep-seated  or  more  distant 
cause  for  their  production  has  been  missed,  and  when,  unfortunately, 
both  patient  and  practitioner  are  often  deluded  into  the  idea  that  a 
disease  has  been  cured  or  eradicated,  of  which  only  the  most  pro- 
minent or  most  distressing  symptoms  have  been  alleviated. 

Thus  guarded,  however,  diagnosis  is  to  the  student  the  best,  nay, 
the  only  legitimate  introduction  to  the  wards  of  an  hospital;  be- 
cause, while  its  simplicity  delights  and  its  approach  to  certainty 
encourages  him,  it  also  best  prepares  him  for  understanding  the  uses 
of  remedies;  it  teaches  him  what  medicine  can,  as  well  as  what 
medicine  cannot,  accomplish ;  it  teaches  him  the  vanity  of  hunting 
after  specifics;  it  saves  him  from  becoming  utterly  skeptic. 

If  it  were  true  that  the  symptoms  by  which  a  disease  is  recog- 
nised were  exactly  analogous  in  all  cases,  it  would  be  enough  that  the 
student  should  commit  to  memory  the  summary  contained  in  sys- 


INTRODUCTION.  19 

tematic  treatises,  when  he  would  be  at  once  in  a  condition  to  pro- 
nounce an  opinion  upon  any  case  put  before  him.  But  this  is  far 
from  being  the  case :  the  idiosyncrasy  of  the  individual,  including  in 
this  term  all  the  differences  exhibited  by  various  persons  in  their  sus- 
ceptibility to  the  influence  of  the  same  noxious  substance  or  ema- 
nation; and  not  less  than  this,  the  varying  power  of  the  causes  of 
disease,  which  though  unproved,  and  perhaps  incapable  of  proof,  we 
cannot  deny,  exerting  an  influence  now  more  potent,  now  weaker; 
the  combination  of  these  two  circumstances  leads  to  an  almost 
endless  variety  in  the  outward  manifestations  of  their  operation 
on  the  human  frame.  The  perplexity  thus  produced  has  led  men 
to  seek  for  some  symptom  which  may  of  itself  determine  the  nature 
of  the  malady,  which  may  be  considered  in  the  common  phrase 
"pathognomonic"  of  the  disease.  Such  simple  indications  would 
be  invaluable  if  they  were  attainable,  but  unfortunately  the  proof 
they  are  supposed  to  afford  is  based  upon  false  induction.  Some 
of  the  greatest  minds  have  fallen  into  this  error,  and  none  mpre 
than  they  who  have  cultivated  the  physical  aids  to  diagnosis,  first 
introduced  by  the  great  Laennec. 

By  means  of  auscultation  and  percussion  we  reach  a  class  of  phe- 
nomena much  simpler,  and  more  nearly  related  to  the  diseased  action, 
than  those  evidences  which  come  to  us  through  the  circuitous  channel 
of  disturbed  function,  reacting  as  every  function  does,  upon  other  or- 
gans, itself  again  altered  or  modified  by  them.  They  are,  in  fact,  the 
necessary  consequences  of  the  morbid  condition  of  the  parts,  but  they 
are  not  the  direct  exponents  of  that  state ;  it  is  only  by  inference  that 
we  deduce  from  the  acoustic  signs  the  nature  of  the  pathological 
change.  With  reference  to  the  lungs,  for  example,  we  learn  by  per- 
cussion the  relative  density  of  the  parts  struck,  but  the  cause  of  that 
density  must  be  proved  by  other  circumstances.  By  auscultation 
we  discover  that  the  air  enters  more  or  less  freely  into  one  portion 
of  the  lung  as  compared  with  another ;  that  it  meets  with  obstacles 
which  produce  certain  sounds ;  that  the  acoustic  properties  of  the 
lung  are  changed  by  disease,  but  the  causes  of  these  phenomena 
must  be  sought  elsewhere  than  in  the  phenomena  themselves.  Crepi- 
tation is  often  spoken  of  as  pathognomonic  of  pneumonia.  Now 
it  is  quite  true  that  clinical  observation  has  shown,  in  a  vast  num- 
ber of  cases,  that  when,  after  death,  fibrin  is  found  effused  into  the 
parenchyma,  such  an  obstruction  to  the  admission  of  air  at  one 
period  exists,  that  it  enters  the  lung  with  a  puff  of  crackling  noise 
called  crepitation;  but  until  it  can  be  shown  that  the  noise  stands 
to  the  fibrin  in  the  relation  of  effect  to  cause,  it  is  a  false  induction 
to  assume  that  it  is  a  certain  evidence  of  its  presence.  And  when 
we  consider  how  possible  it  must  be  that  some  other  cause  of  obstruc- 
tion may  produce  the  same  effect,  or  one  so  nearly  alike  that  it 
cannot  be  distinguished  from  it,  how  possible  that  some  other  sound 
altogether  may  be  mistaken  for  it;  when  we  further  know  that 
both  these  events  do  continually  happen  in  practice,  and  that  cases 


20  INTRODUCTION. 

of  pneumonia  do  frequently  present  themselves  in  which  crepita- 
tion is  not  heard  at  all,  it  will  at  once  be  conceded,  that  though  an 
important  auxiliary,  it  is  not  an  essential  point  in  diagnosis. 

In  another  class  of  diseases,  the  changes  of  structure  are  before 
our  eves;  and  here,  if  at  all,  the  symptom  might  be  regarded  as 
pathognomonic — the  pustules  of  smallpox,  for  example.  But  what 
shall  we  say  of  a  case  when  death  ensues  before  the  pustule  is 
formed?  I  have  seen  differences  of  opinion  prevail  regarding  such 
a  one  only  a  few  hours  before  the  patient  expired.  And  similar 
sources  of  fallacy  might  be  adduced  of  all  corresponding  instances 
of  the  visible,  tangible  results  of  disease. 

A  perception  of  the  errors  arising  from  this  cause  has  led  to  one 
of  an  opposite  tendency,  which  teaches  that  the  general  condition 
of  the  patient  must  be  alone  considered,  and  that  the  name  or  na- 
ture of  the  disease  is  a  matter  of  secondary  importance.  In  the 
hands  of  a  man  of  sound  judgment  and  accurate  perception,  such 
a  c.ourse  is  probably  less  injurious  to  the  patient  than  a  false  con- 
clusion formed  on  insufficient  premises.  Its  peculiar  evil  consists 
in  its  leaving  the  student  without  a  scheme  or  proposition,  around 
which  to  collect  and  arrange  the  multitude  of  distinct  and  isolated 
facts  which  any  case  in  the  wards  brings  before  him.  Few  minds, 
even  those  of  the  highest  order,  are  able  to  divest  themselves  wholly 
of  hypothesis  in  considering  any  series  of  facts;  and  the  more  un- 
trained the  mind  is,  the  more  readily,  does  it  frame  such  hypotheses 
for  the  purpose  of  explaining  them.  By  the  term  explaining  we 
only  mean  the  referring  the  phenomena  to  some  more  general  prin- 
ciple, which  Seems  to  stand  to  them  in  the  relation  of  cause  to  effect, 
and  includes  in  itself  the  whole  or  any  number  of  the  facts  under 
consideration,  as  its  necessary  or  common  results  or  consequences. 
It  is  impossible  to  avoid  affording  such  explanations  to  the  student 
who  is  acquiring  the  principles  of  medicine,  and  it  seems  unwise  to 
discard  them  in  the  wards  of  the  hospital,  where  every  case  ought 
to  be  only  an  example  of  the  doctrines  taught  in  the  schools ;  and 
if  the  teacher  do  not  supply  the  hypothesis,  which  in  any  given  case 
seems  to  him  to  afford  the  true  solution  of  the  phenomena,  the  stu- 
dent will  naturally  frame  one  for  himself,  and  that  probably  an  er- 
roneous one.  At  the  same  time  it  must  be  admitted  by  those  who 
themselves  are  the  most  expert  in  the  practice  of  diagnosis,  that  the 
time  and  the  opportunity  are  not  commonly  afforded  to  give  these 
explanations  at  the  bedside  of  the  patient;  and  clinical  lectures  can 
only  take  up  the  more  prominent  class,  or  the  more  remarkable  in- 
dividual cases  which  at  the  time  happen  to  be  in  the  hospital,  and 
much  of  the  remainder  is  lost  for  the  purposes  of  instruction. 

My  object  in  the  following  pages  is  not  to  supersede  the  teaching 
of  the  clinical  physician,  but  to  meet  this  necessary  imperfection  by 
pointing  out  to  the  student  how  he  may  best  frame  a  true  scheme 
for  himself,  and  still  more  to  aid  him  in  learning  the  lesson  he  is 
daily  taught,  by  rendering  familiar  to  him  the  principles  on  which 


INTRODUCTION.  21 

the  physician  himself  forms  his  opinion.  It  cannot  need  any  de- 
monstration to  show  that  one  who  has  thus  studied  will,  when  him- 
self called  upon  to  prescribe,  all  the  more  readily  seize  on  the  true 
form  of  the  disease,  and  the  exact  relation  it  holds  to  the  vital  con- 
dition of  the  patient. 

In  carrying  out  this  intention  it  would  be  equally  valueless  to 
give  a  mere  enumeration  of  symptoms,  or  to  classify  the  exceptions 
which  experience  has  taught  myself  and  others  to  look  for,  aod  the 
errors  into  which  we  are  liable  to  fall.  My  purpose  is  to  elucidate 
the  principles  as  well  as  the  practice  of  their  interpretation,  so  that 
whatever  be  their  variety  or  perplexity,  philosophical  conclusions 
may  be  drawn  from  their  presence,  avoiding  unwarrantable  infe- 
rences, and  at  least  guiding  the  mind  in  a  right  direction,  if  no  sa- 
tisfactory solution  of  any  individual  case  can  be  arrived  at. 

All  true  diagnosis  is  ultimately  based  upon  inductions  separately 
framed  out  of  clinical  and  pathological  investigations  and  experi- 
ments. By  careful  and  repeated  observation,  we  have  succeeded, 
with  every  appearance  of  truth,  in  associating  certain  phenomena 
observed  during  life  with  particular  lesions  found  after  death ;  and 
these  form  the  first  step  in  our  progress.  Sound  principles  have  ad- 
vanced exactly  in  proportion  to  the  number  and  the  accuracy  of 
these  conclusions,  because  there  are  many  conditions  which  we  are 
not  yet,  and  perhaps  never  shall  be  able,  to  associate  with  any  ap- 
preciable change  in  structure ;  and  to  them  we  must  apply  by  infe- 
rence the  truths  which  have  been  taught  in  other  instances  by  di- 
rect observation.  In  so  far  as  we  are  able  correctly  to  interpret 
symptoms,  and  to  trace  out  in  connexion  with  them  a  real  change 
of  structure  or  of  function  Avhich  affords  an  adequate  explanation  of 
their  presence,  in  so  far  are  we  prepared  to  form  a  correct  diagnosis. 
It  is  not  the  province  of  this  branch  of  study  to  elucidate  the  modus 
operandi  of  the  change;  but,  assuming  these  principles  as  true,  our 
especial  work  is  to  learn  to  group  symptoms  together,  and  to  ana- 
lyze them  separately  in  such  a  manner  that  we  may  be  able  to  ap- 
ply to  them  a  scheme  already  supplied  to  our  hand,  which  shall  in 
some  way  account  for  their  existence.  It  is  by  the  nature  of  this 
assumption  that  rational  medicine  is  distinguished  from  empiricism. 
The  latter  equally  seeks  to  group  symptoms  together,  and  to  assign 
to  each  group  the  most  suitable  remedies ;  but  the  theory  or  scheme 
which  it  furnishes  is  not  based  on  scientific  principles.  In  the  ap- 
plication of  the  theory  to  the  case  under  observation,  the  two  are 
exactly  analogous.  A  comparison  is  to  be  instituted  between  the 
probable  results  of  the  supposed  malady  and  those  presented  by  the 
particular  case,  and  their  correspondence  serves  for  the  verification 
of  the  hypothesis.  In  short,  it  is  the  deductive  process  of  reasoning 
applied  to  the  elucidation  of  morbid  phenomena.  "We  gather  toge- 
ther in  the  best  manner  we  can  the  fragmentary  evidence  of  symp- 
toms, and  we  apply  to  it  the  known  laws  of  causation  taught  by  the 
theory  of  disease. 


22  INTRODUCTION. 

The  correctness  with  which  this  process  is  performed  depends  on 
a  variety  of  circumstances.  In  the  first  place,  it  will  be  greatly  in- 
fluenced by  the  amount  of  evidence.  This  evidence  has  to  be 
sought,  and  therefore  much  will  depend  on  the  manner  in  which  the 
investigation  is  conducted.  "Without  method,  some  portion  of  it  is 
sure  to  be  overlooked  or  forgotten ;  with  a  bad  method,  the  infor- 
mation presents  itself  in  such  a  form  as  makes  the  inference  of 
truth  a  matter  of  difficulty.  The  plan  adopted  in  this  volume  is  one 
which,  on  close  consideration  of  the  subject,  has  most  commended 
itself  to  my  own  mind;  but  each  person  will  probably  be  disposed 
to  modify  it  so  as  to  suit  his  own  habits  of  thought. 

In  the  second  place,  the  correctness  of  the  conclusion  must  very 
greatly  depend  on  our  assigning  the  true  value  to  each  portion  of 
the  evidence,  especially  if  the  group  of  symptoms  be  a  very  complex 
one.  We  still  form  our  judgment  from  the  aggregate,  but  we  know 
that  one  part  is  much  more  trustworthy  and  more  important  than 
the  remainder.  One  single  symptom  even  may,  by  its  presence  or 
absence,  turn  the  balance  of  evidence  in  favour  of  one  disease,  or 
exclude  another;  but  this  view  of  its  importance  in  connexion  with 
the  whole  group,  of  which  it  is  but  a  part,  is  very  different  from  the 
error  already  pointed  out  of  regarding  any  sign  as  "  pathognomonic." 
On  this  point  correct  general  knowledge  of  disease  can  alone  give  pre- 
cision to  our  judgment ;  but  it  is  also  the  province  of  a  work  on  dia- 
gnosis to  assign  in  some  measure  to  each  symptom  its  relative  value. 

In  the  third  place,  the  verification  of  the  result  wholly  depends 
upon  the  accuracy  of  our  knowledge  of  the  theory  of  disease.  The 
evidence  of  symptoms  properly  arranged  leads  us  so  far  in  the  right 
direction  for  discovering  its  true  seat  and  nature;  but  it  does  no 
more  than  point  out  a  number  of  requirements  with  reference  to  par- 
ticular organs,  or  to  the  system  at  large,  which  any  disease  must 
be  known  d,  priori  to  fulfil,  before  we  can  admit  it  to  be  that  which 
exists  in  the  case  before  us. 

From  these  considerations,  I  think -it  must  be  evident  that  the 
more  numerous  and  the  more  simple  the  symptoms  are  on  which  we 
have  to  decide,  the  more  certain  must  be  our  diagnosis. 

Further  illustration  may  perhaps  be  deemed  unnecessary,  but  my  meaning  may 
be  made  more  evident  by  comparing  the  investigation  of  a  case,  to  the  properties 
of  figures  in  geometry.  Suppose  that  through  any  four  fixed  points  straight  lines 
are  drawn  enclosing  a  quadrangular  space:  it  is  manifest  that  the  number  and 
variety  of  figures  which  may  be  produced  is  very  great;  and  if  these  figures  are 
placed  side  by  side  and  compared  with  each  other,  they  will  only  be  recognised  as 
being  four-aided  figures,  and  few  persons  could  find  out  that  they  had  any  other 
property  in  common.  But  if  through  two  of  the  points  (the  first  and  third,  for 
instance)  the  lines  are  always  drawn  parallel  to  each  other,  the  number  of  in- 
stances, is  at  once  much  reduced,  and  this  fact  is  immediately  recognised  as  being 
common  to  them  all.  If,  in  addition  to  this,  the  lines  drawn  through  the  second 
and  fourth  points  are  also  parallel,  the  class  becomes  reduced  to  those  known  as 
parallelograms,  of  which  the  opposite  sides  and  angles  are  equal,  and  the  original 
property  of  their  passing  through  four  fixed  points  becomes  much  more  apparent. 
Further,  if  one  of  the  angles  is  ascertained  to  be  a  right  angle,  we  are  certain  that 
only  one  figure  can  fulfil  all  these  several  indications. 


INTRODUCTION.  23 

Again,  the  parallelograms  may  be  compared  with  each  other  by  the  relative 
length  of  their  diagonals,  and  we'  find  that  in  the  rectangular  parallelogram  the 
two  diagonals  are  exactly  equal.  Here,  then,  we  may  disregard  all  the  other  facts, 
and  finding  straight  lines  drawn  through  four  fixed  points  enclosing  a  quadrangu- 
lar space  of  which  the  diagonals  are  equal,  we  are  certain  that  the  opposite  lines 
are  equal  and  parallel,  that  all  the  angles  are  right  angles,  and  that  only  one  pos- 
sible figure  can  possess  these  two  properties,  just  as  before  we  found  that  only  one 
figure  could  possess  all  the  other  properties  in  detail.  At  the  same  time,  if  any 
one  of  these  properties  could  not  be  detected  on  further  investigation,  we  know 
that  we  must  have  made  some  mistake  in  the  observation  regarding  the  equality 
of  the  diagonals. 

In  studying  disease,  it  is  manifest  that  attention  to  one  symptom 
only  cannot  lead  to  truth,  since  the  causes  of  its  production  may  be 
various;  but  -when  a  greater  number  are  considered,  and  are  found 
to  harmonize  together,  the  possibility  of  the  whole  group  being  pro- 
duced by  one  or  other  of  several  causes  becomes  necessarily  very 
greatly  diminished.  When  the  symptoms  present  are  obscure  or 
uncertain,  it  is  much  more  difficult  to  trace  them  back  to  their  true 
source  than  when  they  are  clear  and  intelligible.  But  yet  we  must 
remember  that  even  after  we  seem  to  have  arrived  at  a  correct  re- 
sult from  the  comparison  of  two  or  more  definite  symptoms,  yet  if 
other  important  phenomena  which  ought  to  be  found  on  closer  search 
are  absent,  we  must  have  committed  an  error  in  observation,  and 
the  opinion  formed  ought  only  to  be  persisted  in  when  this  exact  cor- 
respondence can  be  traced,  or  good  reasons  can  be  assigned  for  the 
existence  of  an  exception.  Hence  it  sometimes  happens  that  future 
examination  of  the  same  case,  by  bringing  to  light  new  symptoms, 
may  oblige  us  to  discard  an  hypothesis  framed  on  insufficient  pre- 
mises: indeed,  we  must  often  suspend  our  judgment  altogether,  till 
the  progress  of  the  case  has  determined  the  actual  form  which  the 
disease  is  about  to  assume. 

Another  point  must  also  be  kept  in  view  in  diagnosis.  Diseased 
action  in  the  body  is  often  very  complex,  and  the  phenomena  pre- 
sent may  not  be  all  reducible  to  the  results  of  one  form  of  disease, 
or  a  morbid  condition  of  one  set  of  organs:  it  may,  on  the  contrary, 
be  compounded  of  the  effects  of  several  causes  acting  together.  And 
not  only  in  such  a  case  are  the  single  effects  associated  together  and 
intermingled  with  each  other,  but  the  product  is  a  combined  effect 
of  the  compound  cause,  in  which  the  direct  symptoms  of  each  sepa- 
rate lesion  are  modified  or  neutralized  by  one  another.  It  is,  there- 
fore, necessary  to  distinguish  between  symptoms  uniformly  asso- 
ciated with  certain  conditions,  and  those  which  are  merely  acci- 
dental ;  these,  again,  must  be  divided  into  phenomena  which,  though 
not  essential,  are  more  or  less  directly  connected  with  the  morbid 
state,  and  those  which  are  wholly  independent  of  it.  And  having 
collected  all  the  evidence  which  the  case  affords,  if  it  appear  suffi- 
cient to  establish  any  hypothesis,  we  have  yet  to  make  sure  that  no 
other  condition  of  disease  is  present  that  might  give  a  different  in- 
terpretation to  some  of  the  symptoms;  and  still  more,  when  it  is 
unsatisfactory  or  contradictory,  must  the  examination  be  careful 


24  INTRODUCTION. 

and  extensive  in  order  to  discover  the  causes  of  this  imperfection, 
and  the  associations  which  modify  or  suppress  those  symptoms 
which  each  would  display  if  acting  alone. 

In  every  one  of  these  points  of  view  it  is  evident  how  much  cor- 
rect diagnosis  must  depend  on  a  knowledge  of  the  true  nature  and 
history  of  disease.  That  alone  can  suggest  trustworthy  hypotheses 
for  the  explanation  of  the  phenomena,  by  bringing  before  the  mind 
the  different  states  which  commonly  give  rise  to  prominent  symp- 
toms, so  that  when  one  fails  to  fulfil  all  the  requirements  of  the  case, 
another  may  be  substituted  for  it;  it  teaches  which  among  the  phe- 
nomena are  important  and  constant  in  their  character,  which  are 
unimportant  and  variable;  it  also  indicates  the  different  diseases 
which  are  most  likely  to  be  associated  together,  and  shows  how  they 
mutually  re-act  upon  one  another.  And  when  we  have  reasoned  to 
the  best  of  our  judgment  upon  the  whole  of  the  premises  submitted 
to  our  consideration,  such  knowledge  can  alone  supply  a  standard 
of  comparison,  whence  we  learn  what  conclusions  have  been  true  or 
false,  as  the  order  of  events  corresponds  to  or  differs  from  that  which 
scientific  experience  teaches  us  to  be  their  known  course  and  progress. 

While  thus  studying  diagnosis,  let  it  not  be  forgotten  that  though 
our  first  aim  be  to  arrive  at  a  correct  conclusion  regarding  the  dis- 
ease under  which  the  patient  is  labouring,  our  ultimate  object  is  to 
restore  health.  Therefore,  while  combining  symptoms  in  our  own 
mind  to  give  unity  to  the  whole,  we  must  ever  have  regard  to  any- 
thing they  may  teach  us  concerning  the  condition  of  the  patient. 
Thus,  for  example,  in  any  case  which  may  at  first  sight  be  regarded 
as  one  of  the  simplest  examples  of  that  state  to  which  the  much- 
abused  term  of  inflammation  is  applied,  however  clear  the  evidence 
in  favour  of  inflammation  of  any  particular  viscus,  we  must  not  act 
upon  this  knowledge  alone,  but  must  take  into  consideration  the 
signs  of  strength  or  weakness,  of  increased  or  depressed  vitality 
which  accompany  it.  This  oversight  is  probably  the  most  prolific 
source  of  many  a  hasty  and  ill-formed  assumption,  based  on  insuf- 
ficient grounds.  The  self-evident  symptoms  alone  are  considered, 
other  phenomena  are  too  often  disregarded,  sources  of  fallacy  are 
overlooked,  and  a  diagnosis  is  pronounced  to  which  the  whole  course 
of  the  disease  is  made  to  bend.  Of  necessity  erroneous  hypotheses 
are  admitted  in  order  to  reconcile  the  evident  discrepancy  between 
the  progress  of  the  case  and  the  supposed  nature  of  the  malady.  Faith 
in  treatment  is  shaken,  because  a  false  opinion  once  formed,  remedies 
cannot  be  employed  in  a  manner  conducive  to  the  recovery  of  the  pa- 
tient. In  the  end,  the  student  becomes  a  fanciful  speculator  in  place 
of  a  sober  physician.  He  finds  the  aimless  impotence  of  quackery 
as  successful  as  his  own  misguided  efforts,  and  follows  the  fashion 
of  the  day  in  homoeopathy,  hydropathy,  the  abuse  of  the  speculum, 
&c,  to  say  nothing  of  the  errors  into  which  some  have  fallen  in  the 
introduction  of  specific  modes  of  treatment,  when  their  position  and 
their  knowledge  had  given  promise  of  better  things. 


25 


CHArTER  I. 

METHOD  OF  DIAGNOSIS. 

History  of  Case — Narrative  of  previous  Symptoms — Arrangement 
of  existing  Phenomena — Plan  of  carrying  on  the  Investigation 
—  Classification  of  Diseases  necessary  to  Diagnosis — Table  of 
Diseases. 

The  discrimination  of  disease,  as  we  have  attempted  to  show,  pro- 
ceeds upon  a  knowledge,  more  or  less  complete,  of  all  the  pheno- 
mena which  any  given  case  presents.  When  it  has  terminated  in 
the  recovery  or  death  of  the  patient,  the  series  of  events  arranged 
in  a  definite  and  intelligible  order,  from  their  commencement  to  their 
conclusion,  is  comprised  under  what  is  called  its  "History,"  which 
ought  to  present  to  the  mind  a  perfect  picture  of  all  its  important 
features.  Unfortunately,  the  perusal  of  the  clinical  case-books  of 
an  hospital,  or  even  the  published  reports  of  cases  by  our  best  au- 
thors, must  convince  us  how  little  the  real  meaning  of  the  history 
of  a  case  is  understood.  Without  the  key  of  a  knowledge  of  the 
disease,  derived  from  some  extraneous  source,  it  will  be  found  too 
often  impossible  to  form  a  correct  diagnosis.  Many  of  the  difficul- 
ties are  inseparable,  to  a  certain  extent,  from  the  nature  and  sources 
of  the  information,  but  many  are  due  solely  to  want  of  system  and 
arrangement. 

The  history  divides  itself  naturally  into  two  parts :  the  report  of 
the  patient  himself,  or  of  his  friends  and  attendants,  of  what  hap- 
pened before  he  was  seen  by  the  physician ;  and  the  phenomena 
actually  observed  at  the  time  of  examination:  the  same  distinction 
must  be  made  between  events  occurring  in  the  absence  of  the  ob- 
server, and  those  noted  at  any  subsequent  visit.  But  as  our  object 
is  rather  to  point  out  the  true  principles  on  which  diagnosis  is  based 
than  to  give  the  history  of  diseased  states,  only  casual  reference 
can  be  made  to  ulterior  changes,  and,  in  general,  it  must  be  pre- 
sumed that  the  previous  history  is  learned  by  report,  while  the  signs 
and  symptoms  are  investigated  as  they  present  themselves  on  a  first 
examination. 

The  previous  history  is  often  of  great  importance ;  it  ought  to 
commence  with  the  very  first  deviation  from  health,  in  so  far  as  the 
sensations  and  functions  of  the  patient  are  concerned,  and  it  ought 
to  give  a  connected  account  of  the  changes  which  have  subsequently 
passed  upon  these,  and  the  origin  of  new  symptoms.  This  account 
is  of  itself  sometimes  sufficient  to  point  out  the  nature  of  the  malady. 
It  seldom  happens  that  all  the  particulars  are  correctly  detailed,  yet 
such  as  it  is,  this  statement  must  very  often  be  appealed  to  in  refe- 


26  METIIOD    OF   DIAGNOSIS. 

rence  to  the  duration,  and  order  of  sequence  of  particular  symp- 
toms, with  a  view  to  determine  their  immediate  precursors,  and  the 
phenomena  which  have  appeared  to  follow  upon,  or  spring  out  of 
them.  Practically  it  will  be  found  that  the  more  perfect  this  infor- 
mation is,  whether  limited  to  the  present  illness,  or  extended  to  a 
perfect  acquaintance  with  previous  ailments,  the  more  valuable  does 
it  prove  as  an  aid  to  diagnosis. 

Much  care  is  necessary  not  only  to  get  at  the  first  deviation  from  health,  but 
also  to  avoid  being  led  away  by  a  preconceived  idea  in  the  mind  of  the  narrator, 
and  the  more  so  if  coming  from  a  scientific  person.  So  much  does  the  mind 
seek  after  causes  of  all  natural  phenomena,  that  the  simplest  and  most  illiterate 
patient  is  more  ready  to  broach  a  theory  of  his  illness,  than  to  tell  his  sensations 
or  his  sufferings. 

It  is  also  to  be  remembered,  that  although  disease  has  a  distinct  and  intelligible 
history,  because  it  follows  a  definite  course,  yet  the  story  of  the  patient  is  often 
inconsistent  with  itself.  General  inconsistency  on  all  points  is  commonly  an  evi- 
dence of  imaginary  hypochondriacal  or  hysterical  maladies.  Partial  inconsistency 
may  arise  from  the  existence  of  different  diseases,  either  simultaneously  or  at  suc- 
cessive periods,  and  the  misplaced  association  of  the  symptoms  belonging  to  each, 
or  simply  from  incorrectness  of  observation. 

Sometimes  the  narration  of  past  sensations  and  sufferings  may  tend  to  lead  the 
observer  away  from  the  true  seat  of  the  malady,  inasmuch  as  not  unfrequently  dis- 
ease of  central  organs  first  makes  itself  known  by  symptoms  in  remote  parts. 
Against  this  there  can  be  no  safeguard  but  a  thorough  knowledge  of  the  relations 
subsisting  between  morbid  states  and  the  possible  phenomena  which  may  attend 
upon  them.  Again,  symptoms  of  importance  may  be  forgotten,  and  circumstances 
which  must  greatly  influence  our  opinion  on  the  case  may  have  been  omitted,  and 
these  points  must  be  inquired  into.  The  same  knowledge  of  the  associations  of 
morbid  states  and  their  phenomena  leads  us  to  ask  such  questions  as  may  deter- 
mine whether  the  symptoms  detailed  have  been  caused  by  one  condition  or  an- 
other (e.  g.,  whether  pain  has  been  caused  by  inflammation  from  the  knowledge 
whether  fever  has  been  present  or  not.) 

Out  of  this  further  inquiry  arises  one  of  the  greatest  and  most  common  sources 
of  fallacy;  and  it  is  great  in  proportion  as  the  history  and  sensations  of  the  pa- 
tient become  the  sources  of  information,  and  the  alterations  in  structure  or  func- 
tion of  which  we  can  take  cognizance  are  few  and  indistinct.  It  springs  from  the 
necessity  of  framing  an  hypothesis  of  the  disease  from  the  general  outline  already 
given  of  the  case,  and  the  anticipation  arising  out  of  this  hypothesis,  that  certain 
phenomena  ought  to  be  present;  in  consequence  of  this  persuasion,  interrogatories 
assume  the  form,  more  or  less,  of  leading  questions,  unconsciously  to  the  inquirer 
himself;  and  this  cannot  fail  to  bias  the  mind  of  the  person  to  whom  they  are  ad- 
dressed. 

This  preliminary  investigation  leads  to  the  association  of  symp- 
toms according  to  their  order  of  sequence,  and  we  must  be  careful, 
by  observing  them  from  another  point  of  view,  to  correct  any  false 
impression  to  which  it  may  have  given  rise.  While,  therefore,  we 
follow  the  patient  telling  his  own  case  in  his  own  way,  it  is  quite 
essential  that  we  should  make  a  subsequent  and  independent  inves- 
tigation of  existing  symptoms  according  to  some  systematic  course, 
which  shall  have  the  effect  of  ranging  them  in  such  scientific  groups 
as  may  most  readily  and  naturally  lead  to  the  detection  of  the  cause 
which  best  accounts  for  their  origin,  and  most  fully  satisfies  all  the 
requirements  of  the  case. 

In  seeking  for  such  an  arrangement,  we  find  that  there  are  two 


METHOD    OF  DIAGNOSIS.  27 

great  classes  of  indications,  the  general  and  the  local;  each  of 
these  comprehending  two  divisions,  the  subjective  and  the  objective, 
the  sensations  of  the  patient,  and  the  alterations  in  structure  or 
function  of  which  the  observer  can  take  note. 

It  may  be  useful  to  notice  here  that  different  names  are  assigned  to  these  phe- 
nomena, as  the  indications  which  they  afford  happen  to  be  derived  from  perver- 
sion of  vital  functions,  or  from  altered  relations  of  parts  to  each  other,  or  to  the 
external  world.  These  are  known  by  the  names  respectively  of  vital  symptoms 
and  physical  signs:  thus,  pain  is  one  of  the  symptoms,  while  swelling  and  redness 
are  among  the  signs  of  local  inflammation;  cough  and  expectoration  represent 
the  symptoms,  the  noises  produced  by  the  meeting  of  air  and  fluid  in  the  bron- 
chia] tubes  are  the  signs  of  bronchitis.  I  believe  this  division  was  intended  ori- 
ginally to  mean  much  more  than  this;  it  was  believed  that  every  disease  had  not 
only  its  category  of  symptoms,  which  might,  any  or  all  of  them,  be  common  to  it 
with  other  diseases,  but  that  each  had  for  itself  its  peculiar  distinguishing  sign  or 
mark,  by  which  it  was  as  readily  recognised  as  by  its  name  (for  instance,  the  rale 
crepitant  for  pneumonia,  the  rale  sous-crepitant  for  pulmonary  cedema,  &c.)  But 
we  shall  find  as  we  proceed  that  the  absence  of  the  sign  does  not  imply  absence 
of  the  disease,  and  its  presence  affords  at  best  only  a  strong  presumption  in  favour 
of  a  certain  condition  of  parts. 

Were  it  constantly  true  that  general  and  local  indications  had 
only  reference  to  a  corresponding  division  into  general  and  local 
diseases,  it  would  be  enough  to  discuss  them  in  this  order ;  but  the 
two  are  so  inextricably  mingled  together,  that  no  more  can  be  done 
than  merely  to  adopt,  so  far  as  possible,  the  plan  of  taking  general 
indications  first,  and  special  indications  afterwards;  for  we  must 
often  reconsider  the  general  symptoms  in  investigating  local  dis- 
ease, as  we  must  also  frequently  anticipate  special  signs  in  inquiring 
into  conditions  of  general  disorder.  No  observation  can  be  con- 
sidered complete  which  has  not  taken  note  as  well  of  the  general 
state  of  the  patient  as  of  the  particular  condition  of  each  individual 
organ,  under  both  these  aspects ;  and  however  we  may  endeavour  to 
simplify  the  inquiry,  omissions  can  only  be  avoided  at  the  expense 
of  occasional  repetition.  It  will  constantly  happen  in  practice  that 
the  same  indication  which  has  been  already  noted  in  regard  to 
duration  and  sequence,  must  again  be  reviewed  both  in  its  bearing 
on  the  general  condition  of  the  system,  and  also  in  its  relation  to 
lesions  of  particular  organs. 

When  the  student  is  introduced  to  the  bedside  of  the  patient,  it  is 
of  great  importance  that  he  should  carry  in  his  mind  a  certain  de- 
finite course  of  inquiry,  according  to  which  hq  should  endeavour  to 
trace  out  a  faithful  history  of  the  case,  so  that  without  any  guide 
but  his  own  investigation,  he  may  be  able  to  frame  a  history  which 
will  leave  him  in  little  doubt  as  to  the  department  in  the  theory  of 
disease  to  which  it  ought  to  be  referred. 

We  are  at  present  only  engaged  in  inquiring  into  the  uses  of  such  an  investi- 
gation, in  so  far  as  it  leads  to  a  correct  diagnosis;  but  every  one  of  the  separate 
features  in  the  picture  may  be  of  importance  in  determining  the  treatment.  Even 
when  a  correct  diagnosis  is  formed,  various  remedies  will  suggest  themselves  to 
the  mind  of  the  practitioner  as  equally  applicable,  and  their  judicious  selection 
very  often  depends  upon  a  due  consideration  of  the  antecedents  and  peculiarities, 


28  METHOD    OF    DIAGNOSIS. 

much  more  than  upon  the  name  given  to  the  disease,  or  the  place  it  may  hold  in 
a  scientific  classification. 

The  student  will  do  well  to  commit  to  writing  the  results  of  his  inquiries. 
There  is  no  means  nearly  so  successful  in  giving  system  and  correctness  to  his 
investigation;  in  no  other  way  can  he  acquire  the  habit  of  observing  all  the  phe- 
nomena of  any  given  case,  or  tracing  their  bearing  on  each  other;  and  nothing 
will  so  effectually  teach  him  to  mark  correctly,  and  estimate  justly,  each  succes- 
sive fact  elicited  by  his  own  inquiries,  or  volunteered  by  the  patient.  From  the 
whole  evidence  thus  faithfully  committed  to  writing  can  he  alone  hope  to  form  a 
correct  diagnosis.  JTis  written  description  ought  to  be  a  full  and  accurate  ac- 
count of  all  that  he  sees,  hears,  feels,  or  even  smells,  and  must  never  embody  any 
conclusions  he  has  formed  from  them  until  the  whole  inquiry  has  terminated. 
Thus,  to  take  a  prominent  example, — in  examining  the  lungs,  however  distinct  he 
may  fancy  the  evidence  of  a  cavity  to  be,  he  ought  never  to  put  down  in  his  notes 
'cavernous  rales,'  or  'cavernous  breathing,'  but  what  he  actually  hears — gurgling 
sounds,  loud  or  very  loud,  blowing,  expiratory  breath-sound,  &c;  everything,  in 
fact,  just  as  it  is  heard;  as  he  proceeds,  it  is  quite  possible  that  other  signs  or 
symptoms  may  be  observed  so  inconsistent  with  the  hypothesis,  that  it  would  be 
quite  unwarrantable  to  assume  the  existence  of  a  cavity — a  conclusion  which 
ought  only  to  be  formed  from  the  coincidence  of  several  other  phenomena. 

The  following  plan  has  seemed  to  me  the  best  adapted  for  obtain- 
ing the  information  required,  and  is  that  which  is  adhered  to  in  the 
following  pages,  but  admits  of  modification  according  to  the  previ- 
ous course  of  study  or  habits  of  the  individual.  It  is  merely  oifered 
as  one  which  has  been  found  practically  most  serviceable  in  making 
available  notes  of  a  large  number  of  cases. 

It  may  be  divided  into  four  principal  sections.  After  a  prelimi- 
nary inquiry  into  the  age,  occupation,  and  habits  of  the  patient, 
and  also  ascertaining  if  there  have  been  any  previous  similar  attacks 
or  any  important  illness,  we  proceed, — 

1.  To  inquire  when  the  first  deviation  from  health  occurred,  how 
it  was  manifested,  and  what  was  the  order  of  sequence  among  the 
phenomena. 

2.  To  examine  into  the  general  state  of  the  patient  at  the  time 
of  observation,  as  manifested  both  by  objective  and  subjective  phe- 
nomena. 

3.  To  make  a  rapid  survey  of  all  the  organs,  especially  with  re- 
ference to  his  sensations. 

4.  While  doing  so,  to  examine  more  particularly  any  organ  to 
which  the  history  of  the  case,  the  general  indications,  or  the  sensa- 
tions of  the  patient  especially  point,  and  now  to  investigate  the  ob- 
jective as  well  as  the -subjective  phenomena  of  the  particular  organ. 

In  short,  we  first  get  all  the  information  we  can  of  what  has  hap- 
pened, we  next  feel  his  pulse,  look  at  his  tongue,  &c,  then  ask, 
with  reference  to  each  of  the  larger  divisions  of  the  trunk,  whether 
he  has  anything  to  complain  of,  stopping  in  our  progress  to  make 
more  minute  investigations  whenever  it  seems  necessary. 

In  endeavouring  to  point  out  to  the  student  the  probable  devia- 
tions from  health  we  may  meet  with  in  various  parts  of  the  body, 
in  the  order  in  which  they  present  themselves  according  to  this  ar- 
rangement, it  will  necessarily  happen  that  the  disease  of  which  they 


TABLE    OF    DISEASES.  29 

are  the  indications  should  be  discussed  in  a  similar  order ;  and  as 
it  is  not  my  wish  to  create  for  diagnosis  a  distinct  place  in  the 
science  of  medicine,  but  to  make  it  subservient  to  practice,  it  seems 
desirable  to  adapt  it  as  much  as  possible  to  a  scientific  and  practi- 
cally useful  classification.  For  this  purpose,  that  has  been  selected 
which  is  in  use  at  St.  George's  Hospital,  which,  it  is  hoped,  will  be 
intelligible  to  all,  as  it  is  most  familiar  to  myself;  but  it  is  not  put 
forward  here  as  possessing  any  claims  to  perfection.  Its  principle 
is — 

I.  To  throw  into  a  large  group  at  the  commencement  all  those 
diseases  which,  while  perhaps  manifesting  themselves  in  particular 
organs,  are  more  or  less  proved  to  have  their  origin  in  general  con- 
ditions of  system. 

This  is  again  subdivided  into  twenty-one  heads,  grouped  in  the 
following  order': — 

1.  Those  which  are  believed  to  have  a  specific  origin;  of  which 
the  febrile  diseases  are  placed  first,  including  many  of  the  so-called 
"zymotics."  Next  come  rheumatism  and  gout,  followed  by  such 
as  are  wholly  adventitious,  the  poisons,  entozoa,  &c. 

2.  Diseases  of  uncertain  or  variable  seat,  dropsies  and  hemor- 
rhages, which,  pathologically,  might  be  regarded  as  merely  indica- 
tions of  deeper-seated  lesion,  but  which,  from  the  consistency  of 
their  signs  and  symptoms  among  themselves,  and  their  dependence 
on  a  variety  of  causes,  also  demand  separate  investigation. 

3.  The  chronic  blood  ailments — purpura,  scurvy,  anremia,  &c. 

4.  The  constitutional  ailments  of  solid  parts ;  scrofula,  tubercle, 
and  morbid  growth. 

5.  The  quasi-nervous  diseases;  the  symptoms  of  which  are  prin- 
cipally derived  from  functional  derangements  of  the  nervous  system, 
in  the  ultimate  distribution  of  its  filaments,  and  in  relation  to  mus- 
cular fibre:  they  thus  stand  in  juxtaposition  to  diseases  of  the  brain 
and  nerves  immediately  following. 

II.  To  take  in  detail  the  diseases  of  special  regions,  or  systems 
of  organs. 

In  this  class  we  commence  with  the  brain  and  nerves,  and  de- 
scend regularly  to  the  thoracic  and  abdominal  viscera,  which  are 
ranged  in  several  groups,  and  we  conclude  with  the  bones,  joints, 
muscles,  and  skin.  In  each  subdivision  the  acute  take  precedence 
of  the  chronic  diseases. 

The  following  table  represents  this  mode  of  classification : — 

I.  Fevers. 

1,  Continued  fever;   2,  Remittent  fever;   3,  Influenza;  4, 
Epidemic  cholera. 

II.  Eruptive  Fevers. 

1,  Measles ;  2,  Scarlatina ;  3,  Varioloid ;  4,  Erysipelas. 

III.  Intermittent  Fevers. 

1,  Quotidian;  2,  Tertian;  3,  Quartan;  4,  Irregular. 


30  TABLE    OF    DISEASES. 

IV.  Rheumatism. 

1,  Acute;  2,  Sub-acute  and  slight;  3,  Chronic. 

V.  Gout  (including  rheumatic  gout.) 

VI.  Poisoning. 

1,  Irritant  poisons;  2,  Narcotic  poisons;  3,  Gaseous  poi- 
sons; 4,  Animal  virus;  a,  Syphilis  and  gonorrhoea;  b, 
Hydrophobia;  c,  Glanders  and  bites  of  reptiles,  &c. 

VII.  Colica  rictonum. 

VIII.  Entozoa. 

1,  Intestinal  worms;  2,  Echinococcus  hominis,  &c. 

IX.  Dropsy. 

1,  Anasarca;  2,  Ascites. 

X.  Hemorrhages. 

1,  Epistaxis;  2,  Haemoptysis;  3,  ILematemesis ;  4,  Ha?ma* 
turia;  5,  Intestinal  hemorrhage;  6,  Uterine  hemorrhage. 
XL  Purpura  and  Scurvy. 

XII.  Anaemia. 

XIII.  Chlorosis. 

XIV.  Cachsemia. 

XV.  Scrofula. 

XVI.  Tubercular  Diseases. 

1,  Phthisis  pulmonalis ;  2,  Tubercles  in  peritoneum ;  3,  Tu- 
bercles in  brain. 

XVII.  Morbid  Growths. 

1,  Cysts;  2,  Encephaloid  cancer;  3,  Scirrhus;  4,  Colloid 
cancer;  5,  Growths  from  bone. 

XVIII.  Hysteria. 

XIX.  Chorea. 

XX.  Delirium  Tremens. 

XXI.  Tetanus. 

XXII.  Diseases  of  the  Brain  and  Spinal  Cord. 

1,  Cephalitis;  2,  Chronic  disease;  3,  Apoplexy;  4,  Epilepsy; 
5,  Functional  disturbance;  6,  Insanity;  7,  Inflammation 
of  cord. 

XXIII.  Paralysis. 

1,  Hemiplegia;  2,  Paraplegia;  3,  Local  paralysis. 

XXIV.  Neuralgia. 

1,  Tic  douloureux;  2?  Sciatica;  3,  Hemicrania;  4,  Angina; 
5,  Other  forms  of  neuralgia. 

XXV.  Diseases  of  the  Heart. 

1,  Pericarditis;  2,  Endocarditis;  3,  Hypertrophy;  4,  Dila- 
tation ;  5,  Valvular  lesion. 

XXVI.  Diseases  of  Blood-Vessels. 
1,  Aneurism;  2,  Phlebitis. 


TABLE    OF    DISEASES.  31 

XXVII.  Diseases  of  the  Respiratory  Organs. 

1,  Laryngitis;  2,  Tracheitis;  3,  Pneumonia;  4,  Pleurisy; 
5,  Pneumothorax;  6,  Bronchitis ;  7,  Emphysema;  8,  Asth- 
ma; 9,  Pertussis. 

XXVIII.  Diseases  of  the  Mouth  and  Pharynx. 

1,  Glossitis  ;  2,  Quinsy ;  3,  Enlarged  tonsils ;  4,  Ulceration ; 
5,  Mumps. 

XXIX.  Diseases  of  the  (Esophagus  and  Stomach. 

1,  Stricture;  2,  Ulceration;  3,  Gastritis;  4,  Dilatation  of 
stomach;  5,  Dyspepsia. 

XXX.  Diseases  of  the  Intestinal  Canal. 

1,  Constipation;  2,  Obstruction;  3,  Enteritis;  4,  Diarrhoea; 
5,  Dysentery ;  6,  Ulceration ;  7,  Tympanites. 

XXXI.  Diseases  of  the  Peritoneum. 

1,  Acute  peritonitis;  2,  Chronic  peritonitis. 

XXXII.  Diseases  of  the  Liver  and  Gall-bladder. 

1,  Inflammation  and  congestion;  2,  Enlargement;  3,  Cir- 
rhosis ;  4,  Jaundice ;  5,  Gall-stones. 

XXXIII.  Diseases  of  the  Spleen. 

XXXIV.  Diseases  of  the  Pancreas. 

XXXV.  Diseases  of  the  Urinary  Organs. 

1,  Nephritis  and  nephralgia;  2,  Abscess;  3,  Ischuria;  4, 
Albuminuria;  5,  Diuresis;  6,  Cystitis. 

XXXVI.  Diabetes. 

XXXVII.  Diseases  of  the  Ovaries. 
1,  Dropsy  ;  2,  Tumours. 

XXXVIII.  Diseases  of  the  Uterus  and  Vagina. 

1,  Amenorrhoea;  2,  Menorrhagia;  3,  Leucorrhcea;  4,  Tu- 
mours; 5,  Prolapsus;  6,  Ulceration;  7,  Congestion;  8, 
Vaginitis. 

XXXIX.  Diseases  of  Bones  and  Joints: 
XL.  Diseases  of  Muscles. 

XLI.  Diseases  of  the  Skin  and  Cellular  Tissue. 

1,  Erythema;  2,  Urticaria  and  roseola;  3,  Lichen  and  pru- 
rigo ;  4,  Squamous  eruptions ;  5,  Vesicular  eruptions ;  6, 
Pustular  eruptions;  7,  Pompholyx  and  rupia;  8,  Vege- 
table parasites;  9,  Tubercle  of  the  skin,  lupus,  &c. ;  10, 
Cellular  inflammation  and  abscess. 

Although  this  arrangement  will  be  followed  as  much  as  possible  in  the  order  of 
investigation  of  symptoms  and  signs,  yet  it  will  often  be  found  matter  of  conve- 
nience to  refer  the  local  symptoms  attendant  on  the  first  great  division  to  the  ex- 
amination of  the  organs  in  which  they  are  severally  found,  and,  in  some  instances 
— as,  for  example,  phthisis — in  which  the  general  symptoms  are  so  essentially 
combined  with  local  changes,  to  defer  almost  the  whole  consideration  of  the  dis- 
ease until  we  come  to  the  organ  in  which  these  changes  occur. 


32 


CHAPTER  II. 

DURATION   AND    SEQUENCE    OF    PHENOMENA. 

Dividing  Diseases  into  Acute  and  Chronic — Long  Ailment — Pain 
in  Reference  to  Duration — Order  of  Sequence — Established 
Course  of  Disease. 

The  inquiry  into  the  first  manifestation  of  any  deviation  from 
health,  the  duration  of  the  disease,  and  the  order  and  sequence  of 
the  phenomena,  is  of  considerable  importance,  as  defining  in  gene- 
ral terms  not  only  the  whole  period  of  the  illness,  but  also  in  some 
measure  the  continuance  of  each  particular  derangement,  and  esta- 
blishing a  certain  relation  between  each  new  phenomenon  and  that 
which  immediately  preceded  it. 

From  the  preliminary  inquiry  as  to  the  age,  occupation,  and 
habits  of  the  patient,  valuable  suggestions  are  sometimes  obtained. 
"We  need  not  dwell  upon  the  variations  in  the  character  of  diseases, 
when  they  occur  in  infancy,  youth,  adult  life,  and  old  age,  because 
these  are  rather  associated  with  stages  of  development  than  with 
periods  of  years;  but  we  may  refer  to  the  information  of  tardy 
growth  or  premature  decay,  Avhich  the  contrast  between  the  actual 
and  the  probable  age  of  the  individual  sometimes  reveals ;  and  to 
the  liability  at  certain  ages  to  the  occurrence  of  specific  diseases. 
In  a  still  more  marked  manner  does  the  occupation  of  the  patient 
become  the  direct  index  of  the  disease  under  which  he  is  labouring, 
as  we  know  that  in  the  pursuit  of  certain  trades  men  are  necessarily 
exposed  to  the  influence  of  various  morbid  agencies.  Nor  less  im- 
portant is  a  knowledge  of  his  previous  habits  in  enabling  us  to 
calculate  the  strength  of  his  constitution,  or  the  tendency  to  un- 
healthy action,  in  warning  us  that  certain  modes  of  treatment  must 
or  must  not  be  adopted,  and  in  pointing  out  the  diseases  which  will 
be  the  probable  consequence  of  baneful  indulgences. 

1.  Duration  divides  diseases  into  acute  or  rapid,  and  chronic  or 
slow. 

2.  It  sometimes  tells  of  a  previous  condition  of  weakness  and 
long  ailment,  which,  though  it  does  not  negative  the  subsequent 
occurrence  of  acute  disease,  guards  against  a  hasty  decision,  and  is 
of  immense  value  in  determining  on  treatment. 

3.  It  gives  a  measure  of  the  intensity  of  pain  and  suffering,  by 
enabling  us  to  compare  its  effect  on  the  patient's  health  with  its 
alleged  duration. 

4.  The  order  of  sequence  helps  us  in  tracing  back  the  phenomena 
of  disease  to  their  origin,  while  the  first  deviation  from  health  some- 
times points  at  once  to  its  seat. 


DURATION  AXD  SEQUENCE  OF  PHENOMENA.     33 

5.  It  sometimes  enables  us  to  exclude  certain  possible  diseases  to 
which  the  symptoms  might  lead,  by  the  knowledge  that  in  their 
course  events  occur  at  fixed  periods,  which  may  have  been  already 
passed  by.  • 

1.  The  question  whether  a  disease  be  acute  or  chronic  is  not  one  merely  of  in- 
tensity. The  clinical  history,  the  pathological  changes,  and  the  treatment,  are  all 
of  them  often  very  different,  not  only  in  degree,  but  also  in  kind.  Little  is  known 
of  the  essence  of  disease;  and  when  similar  causes  give  riseto  somewhat  similar 
groups  of  symptoms,  we  are  content  to  assume  a  similarity  in  the  disease.  This 
we  do  even  when  in  detail  it  may  be  very  difficult  to  point  out  an  exact  resem- 
blance between  any  of  the  particulars  in  two  cases  bearing  the  same  name,  of 
which  the  one  has  been  of  long  duration  and  minor  intensity,  while  the  other  has 
been  of  shorter  duration  and  greater  intensity.  The  name  is  merely  the  mark  or 
sign  by  which  we  agree  to  distinguish  the  group  of  symptoms;  and  its  relation  to 
other  similar  groups  is  conveyed  by  the  resemblance  of  their  denomination.  But 
the  inquiry  has  a  further  application ;  for,  inasmuch  as  the  existing  phenomena 
may  be  produced  by  one  of  two  causes,  of  which  one  develops  its  effects  in  more 
rapid  succession  than  the  other,  the  duration  of  the  disease  will  often  aid  in  deter- 
mining to  which  of  the  two  they  are  to  be  referred. 

2.  Long  ailment  may  imply  either  a  peculiar  susceptibility  in  the  constitution 
of  the  patTent  which  exaggerates  minor  sufferings,  or  an  actual  depression  of  the- 
vital  powers,  from  protracted  illness.  In  each  case,  evidence  of  a  recent  severe 
attack  must  be  unquestionable  before  we  give  our  assent  to  the  existence  of  acute 
disease ;  in  the  one,  because  the  susceptibility  of  the  patient  so  greatly  influences 
the  character  of  the  symptoms;  in  the  other,  because  the  depression  of  the  vital 
powers  renders  the  supervention  of  active  disease  more  improbable,  and  stamps  it 
with  a  character  different  from  that  which  it  has  in  a  healthy  individual.  In  both 
cases,  bearing  in  mind  the  subservience  of  diagnosis  to  treatment,  the  information 
is  most  valuable  in  directing  the  selection  of  remedies. 

3.  The  important  bearing  of  the  duration  of  pain  will  fall  especially  under  con- 
sideration with  reference  to  hysteria  and  neuralgia.  Here  it  may  be  observed  how 
impossible  it  is,  from  the  description  of  the  patient,  to  form  any  idea  of  the  exact 
amount  of  pain  and  suffering,  or  to  institute  any  comparison  between  the  expres- 
sion of  it  as  employed  by  different  individuals.  One  will  talk  composedly  during 
a  severe  operation;  another  looks  pale  and  haggard  and  seems  to  be  in  great  pain, 
perhaps  really  does  suffer  much  from  a  mere  nervous  affection,  which  exists  chiefly 
in  the  imagination,  and  is  principally  maintained  by  the  attention  being  conti- 
nually directed  to  it.  Here,  there  is  the  inconsistency  that  a  very  unimportant 
distraction  serves  to  withdraw  the  attention,  and  thereby  removes  all  recollection 
of  its  existence  and  every  indication  of  its  continuance.  A  third  person  suffers 
severely  from  paroxysms  of  pain,  which  no  amount  of  preoccupation  can  prevent, 
no  distraction  during  its  continuance  can  suspend:  yet  in  this  case  there  may  be 
no  structural  change  to  account  for  the  presence  of  pain.  The  power  of  distract- 
ing the  attention  is  often  the  only  distinction  between  that  which  is  unimportant 
and  transitory,  and  that  which  is  of  grave  import  and  exceedingly  untractable, 
until  its  duration  and  recurrence,  and  the  exhaustion  it  produces,  point  out  its 
reality. 

Duration  is,  therefore,  a  point  of  great  value  in  judging  of  the  intensity  and  im- 
portance of  expressions  of  pain.  a.  Severe  pain  of  long  continuance  must  have 
told  on  the  health  of  the  sufferer,  b.  The  pain  of  a  nervous  affection  may  be 
actuallv  greater  than  that  accompanying  a  severe  disease  in  the  same  locality;  but 
the  continuance  of  disease  produces  far  more  important  changes  than  can  result 
from  the  mere  persistence  of  pain.  c.  When  local  pain  is  of  short  duration,  if  it 
be  only  one  of  the  features  of  long-standing  illness  by  which  the  constitution  has 
not  been  affected,  it  must  be  regarded  as  of  minor  importance. 

4.  A  certain  amount  of  caution  is  necessary  in  adopting  the  patient's  descrip- 
tion of  the  order  of  sequence  of  symptoms.  It  is  remarkable  how,  in  slowly  ad- 
vancing maladies,  nature  accommodates  herself  so  completely  to  immense  altera- 


.1 


1  DURATION    AND    SEQUENCE    OF    PHENOMENA. 


tions  in  structure,  th.it  untiWome  unusual  event  occurs,  the  patient  is  utterly  un- 
conscious of  any  deviation  from  health;  or  it  may  be  there  is  only  a  sense  of 
malaise,  without  the  possibility  of  tracing  this  feeling  to  its  cause,  or  of  naming 
any  Bingle  symptom  which  has  attended  it.  Suddenly  some  change  occurs  of 
which  the  patient  becomes  cognizant,  and  then  other  sensations  which  previously 
existed  take  form  and  shape  in  his  mind,  and  consequently  find  place  in  his  de- 
scription, after  that  which  is  in  reality  their  effect  and  not  their  cause. 

Again,  so  intimate  are  the  relations  maintained  between  all  parts  of  the  body, 
that  it  may  not  be  in  the  very  locality  in  which  disease  has  commenced  that  symp- 
toms of  its  presence  first  arise;  and  hence  it  sometimes  occurs  that  the  first  feel- 
ing of  illness  may  not  directly  point  to  its  true  seat.  This  must  be  corrected  by 
knowledge  of  the  theory  of  disease,  and  the  various  symptoms  by  which  it  is  ac- 
companied. 

With  these  qualifications,  the  first  real  deviation  from  health  is  of  much  value 
in  leading  us  back  to  the  true  seat  of  disease. 

5.  Most  diseases  have  a  certain  established  course,  which,  either  in  broad  and 
general  outline,  or  even  in  minor  detail,  is  followed  by  all  the  examples  coming 
under  observation;  and  although  we  cannot  prescribe  the  exact  limits  of  these  se- 
quences, either  in  days  or  weeks,  in  the  majority  of  instances,  yet  there  are,  in  all, 
general  periods  of  greater  or  less  duration,  during  which  certain  phenomena  must 
present  themselves,  or  else  our  diagnosis  has  been  utterly  at  fault.  This  fact 
forms  one  of  the  elements  of  prognosis,  and  points  out  its  association  with  a  just 
discrimination  of  the  nature  of  a  malady  in  the  first  instance. 


35 


CHAPTER  III. 

GENERAL   CONDITION   OF   THE    PATIENT.  ■ 

Objective  and  Subjective  Phenomena — General  Symptoms;  Skin; 
Pulse;  Tongue;  Bowels  and  Kidneys;  Thirst  and  Hunger — 
Appearance  —  Position  or  Posture  —  Sensations  —  Particular 
Signs. 

We  next  proceed  to  inquire  into  the  general  state  of  the  patient 
at  the  time  of  observation;  our  information  being  derived  from  a 
consideration  of  all  those  phenomena  which  are  not  confined  spe- 
cifically to  any  particular  organ.  They  are  either  objective  or  sub- 
jective. 

Objective  phenomena,  in  their  relation  to  a  general  state,  are 
those  changes  in  the  condition  of  vital  functions  of  which  the  ob- 
server becomes  conscious  by  his  own  perceptions.  They  may,  to  a 
certain  extent,  point  out  the  actual  seat  of  disease,  but  generally 
they  acknowledge  a  variety  of  causes,  and  therefore  only  pave  the 
way  for  further  investigation.  They  are  much  more  trustworthy 
than  subjective  phenomena,  because  to  them  we  can  apply  the  test 
of  experience  and  comparison,  which  gives  them  a  certain  relative 
value,  in  all  cases  in  which  they  are  found.  They  are  independent 
of  the  patient's  sensations  or  imagination,  and  are  less  under  the 
control  of  his  volition;  they  are  therefore  less  liable  to  be  simu- 
lated or  exaggerated. 

Subjective  phenomena  have  special  reference  to  the  sensations  of 
the  patient;  they  express  to  a  certain  extent  his  consciousness  of 
general  derangement  of  vital  functions;  but  their  more  direct  ten- 
dency is  to  point  out  the  particular  function  which  is  disturbed,  and 
hence  the  particular  organ  or  portion  of  the  body  where  disease  is 
located. 

The  two  classes  are  in  great  measure  inseparable.  They  may  be 
divided  into  the  four  following  groups : — 

1.   General  symptoms,  as  pertaining  to — 

a.  Temperature  and  dryness  of  skin; 

b.  Fulness  and  quickness  of  pulse; 

c.  Appearance  of  the  tongue; 

d.  State  of  bowels  and  kidneys; 

e.  Desire  for  food  and  drink. 

It  is  indispensable  to  a  correct  result  that  the  whole  of  these  should  be  always 
taken  together,  as  the  indications  derived  from  one  source  serve  to  correct  those 
drawn  from  another,  and  any  one  of  them  is  valueless  as  standing  alone. 


3G       GENERAL  CONDITION  OF  THE  PATIENT. 

2.  The  general  appearance  of  the  patient: — 

a.  Size,  including  emaciation,  and  increase  of  bulk,  whether 
general  or  local; 

b.  Aspect  of  face,  and  expression ; 

c.  Changes  of  colour  of  skin,  general  and  local. 

3.  His  position,  or  posture: — 

a.  In  bed;   the  manner  of  lying — on  the  back,  on  either 
side;  quiet,  restless,  &c. 

b.  Out  of  bed;  posture,  gait,  stiffness  or  loss  of  power  of 
limbs. 

4.  The  sensations  of  the  patient. 

§  1.  The  indications  of  a  general  condition  of  system,  derived 
from  a  comparison  of  the  symptoms  exhibited  by  the  skin,  pulse, 
tongue,  bowels,  thirst,  and  appetite,  are  of  the  first  importance. 
They  determine  at  once  whether  the  condition  be  one  associated 
with  febrile  disturbance  or  not;  and  in  this  view,  the  intensity  of 
one  symptom  is  of  very  much  less  value  than  the  complete  agree- 
ment of  all.  A  mutual  relation  of  some  of  them  points  out  the 
opposite  conditions  of  vigour  or  weakness,  on  which  so  much  of 
correct  treatment  depends;  while  their  harmony  or  inconsistency  is 
one  of  the  very  first  elements  in  rational  diagnosis. 

a.  The  temperature  of  the  skin  may  be  either  colder  or  hotter 
than  natural,  and  each  of  these  deviations  from  health  may  be  ac- 
companied by  moisture  or  dryness.  This  relation  must  be  consi- 
dered in  determining  the  value  of  the  observation;  heat  and  dry- 
ness generally  becoming  expressive  of  febrile  excitement,  coldness 
and  moisture  of  prostration  and  weakness:  a  hot  and  moist  skin, 
or  a  cold  and  dry  one,  are  each  of  them  less  significant  than  the 
opposites. 

We  have  also  to  pay  attention  to  the  casual  ehanges'in  external  circumstances 
by  which  its  condition  may  be  modified :  such  as  the  effects  of  exercise  or  fatigue  ; 
the  temperature  of  the  surrounding  atmosphere,  and  the  immediate  consequences 
of  exposure;  or  even  the  temporary  effects  of  mental  excitement.  In  ordinary 
changes  of  temperature,  moisture,  by  a  natural  law,  attends  its  elevation,  dryness 
its  depression;  while  these  again  react  upon  each  other,  evaporation  producing 
coolness,  and  vice  versa.  In  disease  this  association  is  sometimes,  but  not  always, 
broken  through ;  and  hence,  while  a  hot,  dry,  and  pungent  skin  indicates  a  febrile 
state,  a  hot  and  moist  skiu  may,  or  may  not,  be  the  consequence  of  disease,  and 
its  value  can  only  be  estimated  by  determining  the  causes  which  have  given  rise 
to  it*  Similarly  a  cold  moist  skin,  in  severe  disease,  is  a  most  alarming  evidence 
of  collapse,  and  a  clammy  skin  generally  indicates  debility,  while  a  cold  and  dry 
skin  is  either  simply  the  effect  of  exposure  in  perfect  health,  or  is  found,  as  the 
cutis  anserina,  at  the  moment  of  rigor  in  fever. 

b.  The  characters  observable  in  the  pulse  are  chiefly  change  of 
rate  or  frequency,  of  volume  or  fulness,  and  of  force  or  firmness. 
These  changes  may  be  considered  as,  to  a  certain  extent,  expressive 
of  really  different  conditions  of  system;  but  here  we  must  rather 
view  them  in  their  relation  to  each  other,  and  to  other  coincident 
phenomena,  among  which,  perhaps,  the  condition  of  the  skin  is  the 


GENERAL    CONDITION    OF    THE    PATIENT.  37 

most  important.  It  is  from  these  two  sources  that  we  derive  evi- 
dence of  the  difference  between  inflammation,  or  inflammatory 
fever,  and  simple  or  continued  fever.  The  skin  is  more  apt  to  be 
moist  when  its  temperature  is  raised  by  inflammation ;  to  be  dry 
when  it  is  the  accompaniment  of  fever.  The  pulse  has  more  fre- 
quency and  less  force  in  fever;  greater  force,  and  commonly  less 
frequency  in  inflammation.  These  distinctions  are  all-important  in 
treatment,  but  in  diagnosis  they  do  no  more  than  give  a  general 
impression  that  one  or  other  condition  is  most  probably  present. 

The  age  of  the  patient  has  an  important  influence  over  the  fre- 
quency of  the  pulse;  sex  and  habit  over  its  fulness  and  firmness. 

The  pulse  may  be  quickened  by  mere  excitement;  the  tongue  may  be  at  the 
same  time  coated  from  disorder  of  the  bowels  ;  but  this  condition  must  not  be  mis- 
taken for  fever,  nor,  if  associated  in  a  delicate  female  with  pain  in  the  left  side, 
be  taken  as  indicative  of  pleurisy.  The  state  of  the  skin,  as  well  as  the  absence 
of  thirst  and  the  character  of  the  urine,  will  here  probably  decide  against  any  such 
supposition.  Acceleration  of  pulse,  to  be  important,  must  be  constant  and  persis- 
tent, not  transient  and  varying  with  temporary  excitement,  &c.  Certain  chronic 
states  are  also  accompanied  by  acceleration  of  pulse,  such,  for  example,  as  heart 
disease  and  phthisis;  and  here  agaiu  the  indications  from  other  sources,  even  with- 
out considering  the  special  indications  derived  from  its  force  or  firmness,  enable 
us  to  correct  an  impression  of  acute  or  febrile  disorder. 

Changes  in  volume  chiefly  give  rise  to  impressions  of  the  pulse  being  full  or 
empty,  large  or  small;  but  these  are  necessarily  associated  with  conditions  of 
hardness  or  softness,  strength  or  weakness,  which  are  expressive  of  changes  in 
force.  The  impressions  of  this  character  are  conveyed  to  the  finger  by  the  greater 
or  less  degree  of  compressibility;  the  pressure  required  to  obliterate  the  current. 
Deviations  occurring  within  the  limits  of  health  generally  combine  fulness  with 
firmness,  weakness  with  smallness.  We  do  not  expect  to  find  a  similar  pulse  in 
a  man  of  sedentary  occupation,  and  in  one  of  active,  or  perhaps  laborious,  pursuits: 
the  pulse  of  the  female  has  neither  the  fulness  nor  the  force  of  the  other  sex. 
And  while  these  point  to  real  differences  in  constitution,  which  guide  us  in  the 
adaptation  of  remedies,  they  are  not  the  less  to  be  borne  in  mind  in  judging  of 
the  extent  of  deviation  in  disease. 

Certain  names  have  been  given  to  unusual  combinations  of  the 
characters  just  mentioned,  with  which  the  student  must  make  him- 
self acquainted:  thus  smallness,  with  force,  gives  rise  to  what  is 
termed  a  hard  pulse,  or,  in  extreme  cases,  a  wiry  pulse;  largeness, 
with  want  of  force,  to  a  soft  pulse;  emptiness  and  frequency  to 
what  is  often  called  a  rapid  pulse. 

Irregularity  of  pulse  has  very  important  bearings  upon  special  forms  of  disease, 
but  is  of  less  consequence  as  a  symptom  of  the  general  condition  of  the  patient. 

c.  The  state  of  the  tongue  is  to  be  noted  with  reference  to  its 
coating  and  its  degree  of  moisture;  and  the  latter  is  probably  of 
more  importance  than  the  former  in  its  bearing  on  our  present  in- 
quiry. The  characters  of  its  coating  are  derived  from  its  thickness, 
extent,  and  colour  or  general  appearance:  whether  it  resemble  a 
thin  coating  of  white  paint,  or  of  paste,  or  be  thick,  like  buff-lea- 
ther ;  whether  the  fur  be  limited  to  the  back  of  the  tongue,  or  the 
tip  and  edges  alone  be  left  clean  and  red,  or  whether  a  red  streak 
be  observed  in  the  centre,  or  the  organ  have  a  general  patchy  ap- 


38  GENERAL    CONDITION    OF    THE    PATIENT. 

pcarancc;  lastly,  whether  the  coating  be  white,  or  yellow,  or  dark 
and  brown.  Sometimes,  on  the  other  hand,  the  tongue  appears  un- 
illy  clean,  and  has  a  smooth  and  peeled  appearance,  or  is  chapped, 
or  marked  by  prominent  papillse.  Each  of  these  conditions  is,  again, 
associated  with  differing  degrees  of  moisture  or  dryness.  Some- 
times the  excessive  moisture  gives  it  an  appearance  of  flabbiness  or 
oedema.  Its  relation  to  the  condition  of  the  bowels  must  not  be 
overlooked. 

No  organ  more  quickly  indicates  derangement,  however  slight:  in  every  state  it 
sympathizes,  and  many  of  the  variations  just  mentioned  have  especial  reference 
to  particular  forms  of  disease:  but  its  varying  characters  have  great  significance, 
as  symptoms  of  the  general  condition  of  the  patient;  the  least  important  being 
that  in  which  the  fur  is  confined  to  the  back  of  the  tongue,  or  is  thick  and  yellow, 
and  bears  evidence  of  large  accumulation.  The  moist,  flabby,  or  cedematous  con- 
dition is  wholly  opposed  to  the  idea  of  febrile  excitement;  the  red  patch  in  the 
centre,  and  the  peeled  or  chapped  condition  of  the  mucous  membrane,  are  very 
important  evidence  of  the  form  which  a  febrile  condition  has  assumed,  but  they 
may  be  in  various  degrees  exhibited  without  the  existence  of  fever,  properly  so 
called:  on  the  other  hand,  a  bright  red  tip  and  edges,  or  a  dark  brown  fur,  are 
more  decidedly  characteristic  of  fever.  As  a  general  rule,  dryness  is  more  indi- 
cative of  a  febrile  state  than  any  appearance  which  the  coating  presents.  Acci- 
dental circumstances  must  not  be  overlooked:  a  patient  in  a  weak  state  waking 
from  a  short  sleep  after  taking  food  will  have  a  dry  tongue;  one  who  has  recently 
taken  any  fluid  will  have  a  moist  one,  in  cases  in  which  neither  condition  is  per- 
sistent or  permanent. 

d.  The  state  of  the  bowels  and  kidneys  is  at  present  to  be  con- 
sidered only  in  general  terms,  whether  there  be  constipation  or  di- 
arrhoea, abundant  or  scanty  discharge  of  urine.  These  questions 
must  again  present  themselves  in  investigating  the  separate  organs, 
but  the  knowledge  of  the  condition  of  the  bowels  is  here  necessary 
to  qualify  the  observations  made  upon  the  condition  of  the  tongue; 
and  the  quantity  of  the  urine  has  a  similar  relation  to  the  existence 
of  thirst. 

In  discussing  the  diseases  of  the  intestinal  canal,  we  shall  have  to  refer  not 
merely  to  the  great  fact  of  the  frequency  of  the  stools,  but  their  appearance  and 
consistence  will  be  found  each  to  have  a  definite  bearing  on  diagnosis.  The  ex- 
istence of  constipation  or  diarrhoea  deprives  a  coated  tongue  of  much  of  its  im- 
portance, considered  with  reference  to  a  general  state  of  system.  Hence  the  value 
of  the  observation  is  in  proportion  to  the  explanation  it  affords  of  the  appearance 
of  the  tongue.  It  is  also  sometimes  suggestive  of  disease  in  remote  organs,  of 
which  the  diarrhoea  of  phthisis,  and  the  constipation  attendant  on  inflammation 
of  the  brain  may  be  taken  as  examples. 

With  regard  to  the  urine  it  may  be  remarked,  that  while  an  abundance  of  pale 
limpid  urine  entirely  negatives  the  idea  of  acute  or  febrile  disease,  an  opposite 
state,  its  being  scanty  and  loaded,  although  a  constant  concomitant  of  such  dis- 
orders, may  depend  on  a  great  variety  of  causes;  and  is  of  importance  chiefly 
when  conjoined  with  thirst.  The  special  diagnosis  must  be  deferred  to  a  later 
stage  of  the  inquiry;  but  in  the  present  day,  with  all  the  advantages  of  chemical 
analysis,  something  more  ought  in  all  cases  to  be  done,  than  merely  to  ascertain 
the  amount  of  the  secretion  or  the  degree  of  its  turbidity. 

e.  In  regard  to  thirst  it  may  be  stated,  as  a  general  rule,  that  the  dryness  of  the 
tongue  and  the  desire  for  liquids  are  proportionate  to  each  other.  All  febrile 
states  present  this  phenomenon  in  greater  or  less  degree,  and  too  much  importance 
must  not  be  attached  to  its  presence,  inasmuch  as  copious  discharges  from  the 


GENERAL    CONDITION    OF    THE    PATIENT.  39 

bowels  or  kidneys  invariably  give  rise  to  it,  whether  tbere  be  fever  or  not.  The 
only  chronic  states  in  which  it  is  very  marked,  are  diabetes,  and  its  simulation, 
diuresis.  In  the  former,  it  is  accompanied  by  hunger  even  in  a  more  remarkable 
degree. 

Loss  of  appetite  is'  so  common  that  it  hardly  needs  to  be  inquired  into,  except 
for  the  purpose  of  noting  as  an  important  symptom  the  circumstance  of  the  appe- 
tite being  unimpaired  in  cases  where  other  indications  would  lead  us  to  expect  it 
should  have  been  lost. 

§  2.  The  general  appearance  of  the  patient  affords  to  the  phy- 
sician very  distinct  indications  of  the  nature  of  the  disease,  and  of 
the  organ  in  which  it  is  probably  located.  This  group  ought  to  be 
studied  with  care,  because  they  are  apt  to  lead  to  hasty  conclusions. 

a.  Alterations  in  general  bulk  are  chiefly  important  as  evidence 
of  long  continued  diseased  action.  Emaciation  implies  imperfect 
nutrition  depending  on  a  variety  of  causes,  which  are  generally 
slow  in  their  operation.  It  also  sometimes  supervenes  very  rapidly 
in  acute  febrile  disorders ;  but  here  the  cause  is  unequivocal.  In 
chronic  maladies  it  arises  either  from  deficiency,  from  waste,  or  from 
perversion  of  the  blood-plasma  or  nutritive  material.  Hence  it  oc- 
curs in  organic  diseases  of  the  abdominal  organs,  in  suppurations 
and  diabetes,  in  phthisis  and  cancer,  in  its  greatest  degrees. 

Along  with  some  general  resemblance  in  all  these  cases,  there  are  certain  spe- 
cial characteristics  forming  part  of  what  may  be  called  the  physiognomy  of  dis- 
ease, which  materially  aid  an  experienced  eye  informing  a  diagnosis  quickly; 
but  too  much  reliance  is  not  to  be  placed  on  them,  and  their  only  use  is  in  direct- 
ing the  practitioner  where  he  is  to  look  for  disease,  the  nature  of  which  must  be 
afterwards  determined  by  its  own  special  phenomena. 

General  increase  of  bulk — obesity,  is  to  be  regarded  as  a  dis- 
eased state,  but  it  cannot  be  traced  to  any  special  organ  as  its  source. 

General  increase  also  arises  from  universal  anasarca,  and  in  rare 
cases  from  universal  emphysema.  The  doughy  feeling  of  the  one, 
accompanied  by  the  remaining  mark  of  the  finger  known  as  pitting 
on  pressure,  contrasts  strikingly  with  the  elasticity  of  the  other,  and 
the  peculiar  sensation  of  crepitation  it  conveys  to  the  hand  of  the 
observer. 

It  is  worthy  of  remark,  that  in  what  has  been  called  acute  dropsy,  especially  as 
occurring  in  children  after  scarlatina,  the  increase  in  size  sometimes  has  a  feeling 
of  elasticity,  and  scarcely  seems  to  pit  at  all.  Firm  continued  pressure  over  a 
superficial  bone,  such  as  the  tibia,  will  remove  any  doubt.  In  such  a  case,  I  have 
heard  the  suggestion  thrown  out  whether  the  case  might  not  be  one  of  emphysema. 

Local  changes  of  size  are  more  particularly  connected  with  local  disease;  those 
which  are  attended  by  increase  will  be  discussed  separately  under  the  head  of 
morbid  growths;  those  of  which  emaciation  is  the  evidence  have  their  source  in 
imperfect  nutrition  of  the  part,  and  are  merely  the  concomitants  of  some  other 
more  important  lesion;  e.  g.,  the  wasting  of  a  limb  which  is  the  subject  of  para- 
lysis. 

b.  Aspect  and  expression  are  to  be  studied  in  their  relation  to 
the  physiognomy  of  disease,  of  which  they  are  most  important  ele- 
ments. The  former  especially  points  to  physical  conditions;  the 
latter  to  the  sensations  of  the  patient,  as  revealed  by  the  features. 
They  are  both  of  much  value,  but  nothing  further  can  be  done  here 
than  to  indicate  this  as  the  direction  in  which  they  must  be  studied. 


40  GENERAL    CONDITION    OF    THE     PATIENT. 

Aspect  tolls  of  a  general  state — cachexia,  tuberculous  or  other,  scrofula,  anaemia, 
&c,  that  which  accompanies  cancer  is  frequently  called  malignant;  or  it  may  tell 
of  ill-ventilated  blood,  of  dissipation,  or  of  exhaustion. 

Expression,  on  the  other  hand,  has  more  distinct  reference  to  the  nervous  sys- 
tem. It  may  be  tranquil,  or  it  may  indicate  pain  or  anxiety;  it  may  be  listless, 
depressed,  wandering,  unmeaning;  or  it  may  be  excited,  or  maniacal.  But,  fur- 
ther, ii  may  be  used  as  a  test  of  the  reality  of  complaints  made  by  the  patient,  or, 
at  least,  of  their  exaggeration;  and  the  rapid  transition  from  smiles  to  tears  in  the 
hysterical  female  is  often  a  valuable  sign. 

Both  are  to  be  noted  with  as  much  precision  as  possible,  because  they  have  an 
important  bearing  on  the  particular  form  which  any  malady  has  taken  or  may 
assume.  The  mind  will  naturally  revert  to  them  in  confirmation  of  an  opinion 
formed  on  other  grounds,  or  as  a  cause  for  modifying  a  conclusion  which  other 
symptoms  might  seem  to  warrant;  and  the  observant  practitioner  will  always  let 
them  have  their  due  weight  in  the  treatment  of  the  case.  It  is  scarcely  necessary 
here  to  remark,  that,  of  the  two  classes,  those  having  reference  to  aspect  are  less 
liable  to  mislead  than  those  derived  from  expression;  the  former  belong  to  objec- 
tive, the  latter  are  in  great  measure  subjective  phenomena. 

c.  Alterations  in  colour  are  in  some  respects  more  specifically  diagnostic;  some- 
times inseparable  from  aspect,  as  the  waxy  complexion  of  chlorosis,  the  pale  puf- 
finess  of  advanced  albuminuria,  the  sallow  hue  of  malignant  disease,  or  the  par- 
ticular blueness  of  the  nose  and  lips  with  dark-coloured  unaerated  blood;  some- 
times distinct  from  it,  as  the  yellowness  of  jaundice,  the  muddiness  of  enlarged 
spleen,  or  the  blueness  of  Asiatic  cholera,  and  the  eruptions  of  measles  and  scar- 
latina. 

Local  changes  may  point  to  a  general  state,  as  in  scurvy  or  purpura,  and  the 
blue  line  of  colica  Pictonum,  or  the  specific  colour  of  syphilitic  eruptions;  to  a 
state  partly  local,  partly  general,  in  erysipelas  or  erythema,  and  the  red  patches 
over  the  joints  in  acute  rheumatism  or  gout;  or  to  a' state  purely  local,  as  in  the 
formation  of  abscess. 

Cutaneous  diseases  are  all  more  or  less  associated  with  local  changes  of  colour, 
which  must  be  particularized  when  this  class  of  diseases  comes  before  us. 

§  3.  The  fact  that  a  patient  is  first  seen  in  bed,  or  going  about 
his  usual  business,  serves  to  give  a  vague  impression  of  greater  or 
less  severity  of  the  attack,  which  may  turn  out  to  be  very  false. 

a.  Position  in  bed  is  to  be  considered  with  reference  to  its  being 
horizontal,  or  more  or  less  erect;  to  the  position  of  the  limbs,  whe- 
ther flexed  or  extended,  fixed  in  one  position  or  moved  freely  about; 
to  the  quietude  or  restlessness  of  the  patient  in  lying,  or  the  main- 
tenance of  a  constant  posture,  whether  on  the  back  or  on  one  side. 
These  circumstances  are  chiefly  indicative  of  the  state  of  respira- 
tion, or  of  sensations  of  pain,  which  are  aggravated  by  one  position 
and  relieved  by  another. 

In  many  instances  the  breathing  is  felt  to  be  much  easier  when  the  head  is 
elevated,  and  occasionally  the  horizontal  position  cannot  be  tolerated  at  all:  to 
this  last  the  name  of  orthopneea  (erect  breathing)  is  frequently  applied.  It  is  in- 
dependent of  frequency  of  respiration,  which  may  attain  to  three  times  its  average 
rate  without  any  consciousness  of  dyspnoea,  and  while  the  patient  prefers  lying 
perfectly  flat  in  bed;  but  it  is  generally  accompanied  by  a  certain  degree  of  hurry 
of  the  breathing.  Such  a  distinction  is  often  to  be  seen  in  the  effects  of  disease 
of  the  heart  or  aorta  upon  the  respiration,  as  compared  with  those  of  lung  disease 
in  phthisis  and  pneumonia.  Occasionally  the  freedom  of  breathing  is  more  in- 
terfered with  by  inclining  to  one  side  than  the  other,  and  this  generally  when  one 
lung  is  from  any  cause  obstructed,  and  free  movement  of  the  ribs  on  the  opposite 
side  is  sought  to  be  obtained  by  elevating  the  shoulder:  this  is  seen  in  cases  of 


GENERAL    CONDITION    OF    THE    PATIENT.  41 

extensive  consolidation  of  one  lung  or  effusion  into  one  pleural  cavity.  But,  on 
the*  other  hand,  pain  on  the  diseased  side  may  be  aggravated  by  such  a  position, 
and  therefore  this  indication  is  by  no  means  a  certain  one. 

Then  again,  pain  of  very  slight  character  in  a  fanciful  person  is  sometimes  said 
to  be  aggravated  by  lying  on  the  affected  side;  whereas  pain  of  a  rheumatic  cha- 
racter may  be  relieved  by  it.  In  congestion  of  the  liver,  although  there  be  pain 
on  the  right  side,  a  still  more  painful  sensation  of  dragging  is  felt  on  turning  to 
the  left.  ^  In  the  pain  of  colic  the  patient  may  receive  so  much  relief  from  pres- 
sure as  to  be  induced  to  lie  on  his  face. 

Pain  dependent  on  inflammatory  action  is  always  increased  by  pressure,  fre- 
quently by  movement,  and  hence  we  may  generally  conclude  that  it  has  this 
source,  when  it  obliges  the  individual  to  maintain  one  constant  posture.  A  most 
striking  instance  of  this  is  afforded  by  acute  peritonitis,  when  the  patient  lies  flat 
on  his  back,  with  knees  drawn  up  and  breathing  restrained,  lest  by  any  possible 
movement  the  pressure  on  the  abdomen  should  be  increased  or  the  relation  of  the 
viscera  disturbed.     What  a  contrast  is  this  to  the  effect  of  pain  in  colic. 

The  absence  of  pain  or  serious  discomfort,  on  the  other  hand,  induces  a  patient 
who  has  any  feeling  of  weakness  to  lie  quiet,  without  his  being  in  any  way  con- 
strained to  remain  in  the  same  position.  This  again  is  very  distinct  from  the  still- 
ness which  is  expressive  of  complete  prostration,  or  of  some  loss  of  muscular  power: 
the  one  patient  may  be  characterized  as  listless,  the  other  helpless.  It  is  impos- 
sible to  describe  all  the  differences  in  words,  and  yet  to  the  experienced  eye  how 
instructive  the  observation.  Watch,  for  example,  the  apathy  of  the  patient  first 
seized  with  malignant  typhus,  and  his  subsequent  helplessness,  and  compare  with 
them  the  quietude  of  the  convalescent,  and  the  powerlessness  of  the  paralytic. 
Observe,  again,  the  marked  stillness  of  acute  rheumatism,  when,  for  example,  the 
patient  sees  some  one  accidentally  about  to  touch  a  painful  joint,  and  knowing 
that  that  touch  is  agony,  yet  he  dare  not  move  the  limb  out  of  danger. 

Information  may  also  be  derived  from  seeing  the  patient  in  bed,  which  may  aid 
in  determining  the  reality  and  amount  of  alleged  want  of  power,  by  ascertaining 
how  far  he  ca°n  move  those  muscles  in  bed  which  seem  to  be  useless  when  he 
is  up.  . 

These  and  similar  indications  must  only  be  trusted  to  in  so  far  as  they  are  borne 
out  by  other  symptoms,  and  in  fact  derive  their  chief  value  from  pointing  out  the 
probable  seat  of  disease  and  leading  to  further  examination. 

b.  Out  of  bed  the  presumption  is  strong,  that  the  disease  is  not 
active  or  acute;  yet  this  is  not  to  be  absolutely  relied  on,  because 
of  the  difference  in  sensations  and  constitution  already  referred  to, 
which  lead  one  person  to  regard  as  trivial  what  is  considered  of  se- 
rious import  by  another.  An  erect  posture  indicates  a  state  of  ge- 
neral health  and  strength,  and  freedom  of  respiration;  a  crouching 
one,  general  feebleness,  or  laboured  breathing.  The  gait  may  be 
halting  on  one  side,  or  equally  imperfect  on  both;  and  here  it  is 
very  important  to  notice,  whether  the  imperfection  arise  from  stiff- 
ness, or*  loss  of  power;  in  the  one  case  the  movement  is  firm  and 
steady,  though  impeded;  in  the  other  it  is  irresolute  and  unsteady. 

The  action  in  rising  up  or  sitting  down  is  often  of  use  in  determining  this  point 
with  reference  to  the  legs:  and  in  the  upper  extremities  the  dropping  of  the  limb 
when  raised  by  the  hand  of  the  observer  best  discriminates  these  conditions.  rILe 
features,  too,  are  sometimes  distorted  by  partial  loss  of  power. 

Paralysis  will  be  subsequently  discussed.  Stiffness  leads  to  inquiry  into  the  state 
of  the  joints,  and  especially  as  to  rheumatic  affections. 

As  a  striking  contrast  to  these  conditions,  we  have  the  involuntary  jerking 
movements  of  chorea,  and  the  quick,  hurried  and  rather  tremulous  actions  of  de- 
lirium tremens;  we  may  also  observe  the  inconsistent  proceedings  of  one  com- 
pletely delirious,  and  the  perverse  stupidity  of  the  imbecile. 


1-  SPECIAL   INDICATIONS. 

I.  The  sensations  of  the  patient  have  not  much  relation  to  his  general  state. 
They  include  those  pertaining  to  temperature,  of  excessive  heat  or  cold,  feverteh- 

or  chilliness,  which  Bomelimea  contrast  .strangely  with  the  actual  temperature 
of  the  skin:  feelings  of  weakness,  malaise,  or  pain;  insomnia,  giddiness,  or  head- 
ache;  Bhortness  of  breathing;  hunger,  thirst,  and  their  opposites; — all  the  sub- 
jective phenomena,  whether  related  in  the  history  of  the  case,  or  in  answer  to  our 
inquiries  regarding  general  symptoms,  serve  to  point  out  the  direction  which  sub- 
Bequent  investigations  ought  to  take.  We  note  not  only  their  actual  existence  at 
the  time,  but  also  their  previous  occurrence  in  the  past  history  of  the  case;  both 
in  their  bearing  on  the  general  state  of  the  patient,  and  in  the  light  they  mav  throw 
upon  special  pathological  conditions,  when  the  various  organs  subsequently  pass 
under  review,  bearing  in  mind  the  sympathetic  and  indirect,  as  well  as  the  more 
evident  and  more  direct  sensations.  Sometimes  they  are  such  as  we  feel  assured 
can  have  no  existence  in  reality,  and  then  we  are  led  to  inquire  into  disordered 
innervation,  distorted  imagination,  or  perverted  function  of  the  brain. 

This  is  the  proper  period  of  the  examination  at  -which  to  inquire 
what  the  patient  has  to  complain  of.  We  are  preparing  to  enter 
into  the  investigation  of  the  special  phenomena  of  disease,  and  it  is 
a  good  plan  to  ascertain,  first,  in  what  direction  the  sensations  of 
the  patient  point.  Then  it  is  important  to  remember  that  every 
person  has  a  tendency  to  express  a  theory  of  his  malady,  rather 
than  to  relate  the  simple  facts  of  which  his  sensations  have  made 
him  conscious;  not  satisfied  with  the  knowledge  that  such  and  such 
effects  have  followed,  he  always  fixes  his  mind  on  what  he  assumes 
to  be  their  cause,  and  when  asked  what  he  has  to  complain  of,  his 
answer  is  commonly  framed  in  the  language  of  this  theory.  The 
French  physicians  have  a  form  of  question  which  seems  to  me  very 
well  suited  to  avoid  this  evil ;  they  ask,  "  ou  avez  vous  mal?"  and 
it  would  be  well  to  adopt  something  of  the  same  kind  among  our- 
selves, rather  to  ask  where  is  the  complaint,  than  what  it  is. 

In  making  the  observations  which  have  just  been  detailed,  it  not  unfrequently 
happens  that  some  particular  or  unusual  condition  is  present,  which  of  itself  has 
a  direct  bearing  upon  the  diagnosis  of  the  disease ;  not,  let  it  be  understood,  as  a 
distinctive  mark,  or  special  diagnostic  sign,  but  as  a  phenomenon  which,  in  the 
majority  of  instances,  has  been  found  associated  with  only  one  form  of  disease,  or 
at  least  with  a  comparatively  small  variety  of  cases.  Some  of  these  are  very  dis- 
tinct and  unmistakeable,  while  others  scarcely  admit  of  description,  and  are  only 
learned  by  repeated  observation.  Even  to  the  most  practised  eye,  such  signs  are 
more  or  less  uncertain,  and  the  student  should  never  place  reliance  on  them: 
they  are  but  solitary  indications,  and  his  object  should  be  to  acquire  accurate 
knowledge,  which  is  only  to  be  obtained  by  testing  conclusions  drawn  from  one 
series  of  observations,  by  others  which  are  as  distinct  from  them  as  possible.  The 
sources  of  fallacy  which  especially  affect  all  these  special  indications  have  been 
already  noticed,  and  it  is  most  essential  to  remember  that  they  have  no  necessary 
or  absolutely  inseparable  connexion  with  any  one  single  morbid  state,  to  the  ex- 
clusion of  all  others.  The  deeper  seated  the  lesion  in  all  these  cases,  the  more 
liable  are  we  to  fall  into  error.  It  surely  needs  no  argument  to  prove  that  instead 
of  trusting  to  such  special  signs,  a  systematic  examination  of  the  whole  symptoms 
of  t  lie  case  may  not  only  lead  to  the  discovery  of  some  other  disease  in  addition  to 
that  which  the  particular  sign,  however  truthful,  may  have  indicated,  but  it  may 
also  point  out  peculiarities  in  the  case  under  observation  which  a  more  cursory 
view  must  overlook;  and  with  reference  to  treatment,  both  these  of  circumstances 
are  of  much  importance.  A  few  of  these  indications  are  here  ranged  under  the 
Jbur  groups,  under  which  the  subject  generally  has  been  reviewed,  several  of  them 
liaving  been  already  incidentally  mentioned. 


.  SPECIAL   INDICATIONS.  43 

Particular  indications  derived  from  Group  I. 

a.  The  skin. 

a.  The  skin  feels  peculiarly  thin  and  detached  from  the  subcutaneous  structures 
in  phthisis:  and  to  a  less  degree  also  in  similar  wasting  diseases. 

8.  A  feeling  of  fulness  and  tension  exists  in  the  eruptive  fevers,  amounting  to 
a  sense  of  hardness  in  erysipelas,  and  of  grittiness  in  small-pox. 

y.  The  nails  become  clubbed  and  the  hair  falls  off  in  tubercular  disease,  but 
these  circumstances  are  not  limited  to  such  cases:  in  secondary  syphilis  the 
hair  also  falls,  and  during  recovery  from  fever. 

8.  Disease  of  the  abdomen,  especially  of  a  tubercular  character,  is  often  accom- 
panied by  a  dry,  harsh  state  of  skin,  which  is  most  marked  in  childhood. 

i.  The  skin  is  remarkably  moist  and  soft  in  delirium  tremens. 

£.  The  perspirations  are  profuse  and  sour-smelling  in  acute  rheumatism,  but 
this  is  not  specifically  diagnostic  as  has  been  supposed.    In  some  of  the  m 
intractable  forms  of  the  disease,  the  odour  is  peculiarly  rancid  and  disagree- 
able.    Excessive  perspiration  of  any  kind  is  frequently  attended  with  an  erup- 
tion of  miliary  sudamina. 

rt.  Colliquative  sweats  are  constant  attendants  on  the  later  stages  of  phthisis  and 
on  profuse  suppuration,  such  as  lumbar  abscess. 

6.  Rigor,  as  indicated  by  the  cutis  anserina,  is  the  common  precursor  of  fever; 
its  recurrence  at  intervals,  if  not  from  the  presence  of  ague,  or  its  sudden  su- 
pervention during  any  existing  illness,  is  indicative  of  the  formation  of  pus. 

x.  The  crackling  feeling  of  emphysema,  and  the  doughy  character  and  pitting 
uuder  pressure  of  anasarca  are  each  very  characteristic. 

(See  also  changes  of  colour.) 

b.  The  pulse. 

a.  When  frequent,  the  pulse  is  observed  to  be  remarkably  full  in  acute  rheuma- 
tism, and  generally  firm  in  all  acute  inflammatory  diseases. 

,6.  It  is  hard  and  wiry  in  abdominal  inflammations  especially. 

y.  It  is  weak  in  fevers,  properly  so  called ;  either  large  and  soft,  or  small  and 
feeble. 

S.  It  is  rapid  and  jerking  in  hemorrhage. 

f.  It  is  simply  hard  and  unyielding  in  old  age,  and  in  all  conditions  of  arterial 
degeneration. 
_     f .  The  rapidity  or  shortness  of  the  stroke  is  very  observable  as  an  indication  of 
excitement. 

!».  Its  frequency  is  most  remarkable  in  acute  hydrocephalus,  varying  with  un- 
appreciable  causes,  and  generally  uneven  or  unequal. 

0.  It  is  still  more  unequal  and  depressed,  or  it  is  slow  and  laboured,  in  cerebral 
disease,  especially  where  the  case  is  marked  by  pressure  on  the  brain. 

x.  Irregularity  of  the  pulse  is  most  commonly  associated  with  disease  of  the 
hearf,  and,  along  with  this,  it  is  remarkably  faint  and  feeble  if  there  be  mitral 
regurgitation. 

?..  A  hammering  pulse  indicates  aortic  regurgitation. 

,u.  The  pulse  becomes  imperceptible  in  syncope  and  in  cholera,  and  more  or 
less  faint  in  all  conditions  of  collapse. 

v.  It  is  sometimes  felt  only  at  one  wrist,  when  disease,  chiefly  in  the  form  of 
aneurism,  affects  the  origin  of  the  subclavian,  on  the  opposite  side.  More 
rarely,  this  circumstance  is  the  effect  of  accidental  obliteration. 

c.  The  tongue. 

a.  The  thin  white  even  layer  is  generally  indicative  of  slight  gastric  disorder. 

,8.  The  thicker  coating,  from  accumulation,  exists  to  its  greatest  extent  in  affec- 
tions of  the  fauces,  and  less  remarkably  in  conditions  of  general  debility:  it 
has  a  creamy  look  in  delirium  tremens. 

y.  A  peculiar  buff  leather  appearance  is  presented  in  cases  of  enteritis  and  he- 
patitis. 

6.  A  patchy  tongue  is  often  indicative  of  considerable  irritation,  or  even  partial 
inflammation  of  the  stomach. 


44  SPECIAL    INDICATIONS.  # 

i.  Its  yellow  colour  is  generally  believed  to  be  bilious;  a  dark  brown  colour  ex- 
ists only  in  malignant  fever,  and  in  hemorrhage  from  the  mouth. 

C.  The  shining  ami  glased  tongue,  especially  when  chapped,  is  very  common  in 
ulceration  of  the  bowels. 

r.  The  papillae  project  most  remarkably  in  scarlatina;  the  general  surface  being 
either  coated  or  unusually  red,  (the  strawberry  tongue.) 

6.  A  less  degree  of  projection  through  a  thin  white  coating  often  accompanies 
hysteria. 

x.  Aphthae  and  ulcerations  indicate  imperfect  nutrition,  and  tendency  to  diar- 
rhoea. 

d.  1.  The  character  of  the  stools. 

o.  Motions  simply  watery  are  the  characteristic  of  diarrhoea,  and  their  opposite, 

of  a  Condition  of  constipation. 
/3.  Undigested  food  is  sometimes  seen  in  the  stools. 
y.  They  are  of  an  ochrey  colour,  as  well  as  thin  and  watery,  in  fever. 
6.  They  resemble  rice-water  in  cholera. 

c  The  feces  pass  in  scybalous  lumps,  with  blood  or  mucus  in  acute  dysentery. 
C.  Mucous  and  purulent  discharges  are  seen  in  the  same  disease  in  its  chronic 

form  ;  pure  pus  comes  away  when  an  internal  abscess  discharges  itself  by  the 

intestinal  canal. 
r.  The  motions  are  black  and  pitchy  when  blood  becomes  mixed  with  the  in- 

gesta  in  the  stomach,  or  upper  part  of  the  canal. 
0.  They  are  streaked,  or  more  or  less  mixed  with  blood  of  more  natural  colour 

in  hemorrhoids,  and  hemorrhages  lower  down  in  the  canal. 
x.  The  stools  are  clay-coloured  in  deficiency  of  bile. 
x.  They  are  sometimes  frothy  and  yeasty-looking,  as  if  fermentation  had  taken 

the  place  of  digestion. 
p.  They  may  contain  fluid  fat,  which  solidifies  on  cooling;  this  is  sometimes 

connected  with  pancreatic  disease;  or,  they  may  contain  biliary  calculi,  in- 
testinal worms,  and  even  calculi  from  the  kidney. 
v.  Occasionally  the  form  of  the  evacuation  is  altered  by  passing  through  a  stric- 

tured  portion  of  the  gut,  when  that  is  placed  near  its  lower  orifice. 

d.  2.  The  character  of  the  urine. 

a.  It  is  remarkably  pale,  limpid,  and  abundant  in  hysteria,  but  not  persistently  so. 
(3.  It  is  generally  dark-coloured,  with  or  without  deposit  on  standing,  in  febrile  ^ 

states. 
y.  There  is  a  copious  deposit  on  cooling,  when  the  watery  portion  is  deficient, 

and  much  acid  is  secreted. 
8.  It  gives  a  red  stain  to  the  utensil  in  disorder  of  the  liver,  in  connexion  with 

the  foregoing  state. 
i.  It  presents  a  dark  porter  colour  in  jaundice,  from  the  presence  of  bile, 
f.  It  has  a  smoky  colour  from  altered  blood  when  acid,  and  a  pinkish  hue  when 

alkaline;  becoming  quite  crimson  when  much  blood  is  passed. 
r.  The  conditions  of  albuminuria,  pyuria,  and  diabetes,  the  characters  of  the 

sediments,  and  the  effect  of  chemical  re-agents,  will  be  afterwards  noticed. 

e.  1.  The  appetite  becomes — 
a.  Excessive  in  diabetes. 

|3.  Craving  in  mesenteric  disease,  or  when  intestinal  worms  exist. 

y.  Depraved  in  hysteria — eating  of  chalk,  cinders,  slate-pencil,  «fcc. 

S.  Fanciful  in  pregnancy;   expressed  as  longings  for  certain  articles. 

i.  It  is  very  variously  altered  in  dyspepsia. 

f.  The  name  of  bulimia  has  been  applied  to  that  conditiou  which  seems  to  con- 
sist in  nothing  more  than  extraordinary  voracitv. 
c.  2.  Thirst— 

a.  Is  remarkably  increased  in  diabetes. 

(3.  It  is  very  urgent  in  cholera,  and  also  in  a  less  degree  in  diarrhoea. 

y.  Diuresis  with  uncommon  thirst,  when  no  sugar  passes  in  the  urine,  is  gene- 
rally due  to  hysteria;  it  is  not  attended  with  hunger. 


SPECIAL    INDICATIONS.  45 

Particular  indications  from  Group  II. 
a.  1.  Emaciation  seems  to  affect — 

a.  More  especially  the  arms  and  thorax  in  phthisis,  and  the  face  least. 
p.  The  lower  limbs  and  the  face  in  abdominal  disease, 
y.  It  is  most  marked  in  the  features  in  malignant  disease. 

a.  2.  Local  increase  of  bulk  becomes  remarkable — 

o.  When  the  upper  half  of  the  body  is  anasarcous  and  not  the  lower,  or  when 

one  limb  only  is  cedematous. 
/3.  When  the  head  is  enlarged  in  chronic  hydrocephalus. 
y.  When  one  side  of  the  chest  or  the  abdomen  projects  from  effusion  of  fluid, 

or  internal  tumour. 

b.  1.  The  aspect  is  often  very  significant. 

a.  A  delicate  appearance,  with  long-fringed  eye-lashes,  often  serves  to  point  out 
the  tubercular  diathesis. 

p.  The  thickened  alaj  of  the  nose  and  upper  lip  of  scrofula  are  most  marked  in 
childhood. 

y.  The  pallor  of  anaemia  is  very  important;  it  is  waxy  in  chlorosis,  and  pasty 
in  disease  of  the  kidney. 

8.  A  puffy  appearance  about  the  eyelids,  along  with  anaemia,  is  very  generally 
the  indication  of  albuminuria. 

i.  The  sallow  hue  of  the  malignant  disease  appears  to  be  only  another  form  of 
anaemia. 

£.  The  blue  colour,  especially  of  the  nose  and  lips,  in  heart  disease  and  chronic 
bronchitis,  is  equally  remarkable,  and  forms  a  striking  contrast  to 

»;.  The  dusky  flesh  of  pneumonia,  or 

6.  The  hectic  flush  of  phthisis. 

x.  The  congested  features  and  suffused  eyes  of  typhus  are  exceedingly  charac- 
teristic. 

%.  A  bloated,  blotchy  face  generally  indicates  irregular  habits  of  living. 

ix.  The  features  undergo  remarkable  change  in  erysipelas,  parotitis,  facial  para- 
lysis, &c. 

b.  2.  Expression. 

a.  The  face  is  remarkably  anxious  in  disease  of  the  heart,  and  in  urgent  dys- 
pnoea, e.  g.,  laryngitis. 

p.  It  is  at  the  same  time  pinched  and  contracted  when  there  is  much  pain  or 
suffering,  especially  in  a  vital  organ. 

y.  Its  immobility  is  most  remarkable  in  catalepsy  or  in  states  of  unconscious- 
ness, and  perhaps  under  the  influence  of  spasm,  as  in  tetanus. 

5.  The  opposite  state  exists  in  nervousness  and  hysteria. 

i.  The  expression  of  the  countenance  is  most  materially  altered  by  the  swelling 
of  oedema  or  erysipelas.  (Many  of  its  characters  have  direct  reference  to  the 
brain,  in  treating  of  which  they  will  be  further  discussed.) 

c.  Alterations  of  colour. 

a.  The  whiteness  of  the  skin  is  remarkable  in  all  the  varieties  of  anaemia  already 
noticed,  and  contrasts  strongly  in  limbs  anasarcous  from  albuminuria  with 
those  in  which  dropsy  is  connected  with  disease  of  the  heart.  It  is  also  very 
striking  in  phlebitis  (phlegmasia  dolens.) 

|9.  There  is  a  certain  yellowness  of  the  malignant  aspect,  which  is  distinguished 
from  jaundice  by  the  pearly  lustre  of  the  eyes. 

y.  The  yellowness  of  jaundice  varies  from  a  pale  orange  to  a  deep  green-yellow. 

i>.  Redness  of  skin,  when  local,  indicates  congestion;  when  general,  is  more  fre- 
quently due  to  measles  or  scarlatina,  or  simply  to  febrile  heat.  It  is  the 
marked  characteristic  of  erysipelas,  erythema,  gout,  and  acute  rheumatism. 

i.  The  skin  has  a  muddy  hue  in  disease  of  the  spleen. 

f.  It  becomes  blue  in  Asiatic  cholera;  it  is  also  blue  in  morbus  caeruleus,  and 
in  forms  of  diseased  heart  and  bronchitis. 


4G  SPECIAL    INDICATIONS. 

r.  Tt  is  livid  in  commencing  gangrene;  and  it  might  also  sometimes  be  called 

livid  in  disease  of  the  heart. 
6.  Spots  and  patches  of  discoloration  are  of  value  in  recognising  certain  fevers, 

purpura  and  scurvy,  colica  pictonum,  syphilis,  and  most  cutaneous  affections. 


From  ( I ROTTP  III.  a  very  large  number  of  particular  indications  might  be  drawn  : 
we  shall  here  enumerate  only  the  more  important. 

a.  Position  in  bed. 

o.  The  head  is  elevated  chiefly  in  disease  connected  with  the  heart,  less  fre- 
quently in  diseases  of  the  lungs. 

/?.  The  head  is  leant  forward  when  there  is  pressure  on  the  trachaea. 

y.  The  patient  may  be  unable  to  lie  down  from  pain  of  head  or  "iddiness. 

h.  Lying  on  the  back  is  the  position  of  debility;  it  is  then  combined  with  list- 
lessness:  it  is  also  the  position  of  paralysis,  when  it  is  combined  with  inability 
to  alter  it;  and  of  stiffness  and  pain  in  acute  rheumatism,  when  it  is  chiefly 
characterized  by  stillness. 

t.  The  same  position  is  generally  assumed  in  acute  peritonitis,  when  it  is  com- 
bined with  drawing  up  of  the  knees  towards  the  abdomen. 

f.  The  patient  assumes  a  prone  position  generally  only  in  abdominal  spasm  or 
colic:  much  more  rarely  in  consequence  of  the  pressure  of  internal  tumour. 

rr  When  fixed  on  one  side,  we  may  generally  assume  that  the  breathing  is  much 
obstructed  in  the  lung  of  that  side  on  which  he  lies.  When  he  is  unwilling 
to  turn  to  either  side,  it  is  commonly  from  the  sense  of  pain  accompanying 
inflammation;  pressure  produces  pain  on  the  affected  side,  while  turning  on 
the  opposite  causes  a  sensation  of  dragging. 

b.  Posture  and  gait. 

a.  Inability  to  stand  depends  on  weakness,  vertigo,  or  paralysis:  in  the  two  for- 
mer the  patient  reclines,  in  the  latter  he  sits. 

p.  The  body  is  bent  to  one  side  in  curvature  of  the  spine,  and  also  in  disease  of 
the  hip. 

y.  The  gait  is  quick  in  excitement; 

8.  Slow  in  debility; 

t .  Laborious,  staggering,  or  uneven  in  diseases  of  the  brain  and  paralysis. 

£.  It  is  stiff  and  halting  in  rheumatism  and  disease  of  joints. 

rt.  There  is  constant  movement  in  chorea. 

6.  Tremor  exists  in  nervousness,  and  more  especially  in  delirium  tremens;  it  is 
seen  in  fever,  sometimes  with  what  is  called  floccitatio;  it  also  accompanies 
severe  rigor. 

x.  Tonic  spasm  occurs  in  tetanus,  in  disease  of  the  spinal  cord,  poisoning  with 
strychnia,  &c.  When  long  continued,  it  is  probably  associated  with  inflam- 
matory softening  of  the  brain. 

a..  Catalepsy  is  a  peculiar  form  of  tonic  spasm;  cramp  is  its  mildest  manifesta- 
tion. 

ju.  Clonic  spasm  occurs  in  epilepsy,  eclampsia,  chorea,  and  hysteria :  subsultus 
is  also  a  form  of  clonic  spasm,  allied  to  tremor. 

v.  The  muscular  movements  generally  are  exalted  in  mania  and  delirium,  are 
diminished  in  idiotcy  and  imbecility,  are  lost  in  paralysis.  There  is  a  certain 
restlessness  sometimes  belonging  to  hypochondriasis,  and  more  rarely  to  hys- 
teria, allying  them  with  delirium  in  this  external  manifestation. 


Groit  IV.,  when  applied  as  particular  indications  referring  to  disease  in  dis- 
tinct organs,  would  include  the  whole  of  the  subjective  phenomena  of  disease. 
Here  we  can  only  point  out  one  or  two  which  are  remarkable  for  their  indirect  in- 
dications:— 

a.  The  contrast  in  genuine  cholera  between  the  corpse-like  coldness  of  the  body 


SPECIAL    INDICATIONS.  47 

and  the  sensation  of  heat  with  which  the  patient  is  oppressed ;  in  diarrhoea 
there  is  generally  chilliness. 

(3.  As  a  sensation  of  an  opposite  kind,  may  be  mentioned  the  common  complaint 
of  chilliness  in  fever  when  the  skin  is  burning  hot. 

y.  The  sensations  of  the  hypochondriac  are  opposed  alike  to  the  evidence  of  the 
senstB  and  the  conclusions  of  reason. 

S.  A  patient's  complaint  of  want  of  sleep  is  almost  certain  to  be  exaggerated : 
the  report  of  the  nurse  or  attendant  can  alone  be  relied  on. 

t.  The  sympathetic  pains  form  an  important  group.  Thus  pain  of  the  right 
shoulder  may  proceed  from  disease  in  the  liver;  pain  of  the  sacrum,  from 
disease  of  the  uterus;  of  the  thigh  and  testicle,  from  nephritis  or  nephralgia; 
of  the  knee,  from  disease  of  the  hip  ;  of  the  meatus,  from  stone  in  the  blad- 
der, &c. 

£.  Complaints  of  pain  are  often  exaggerated  in  persons  of  nervous  susceptibility. 

In  this  enumeration  let  it  be  remembered  that  the  circumstances 
detailed  only  give  us  hints  of  what  we  may  suspect,  that  they  afford 
no  certainty:  and  I  think  it  will  be  found  that  the  physician  who 
is  most  familiar  with  such  indications,  and  who  sometimes  astonishes 
by  the  rapidity  with  which  he  arrives  at  a  correct  conclusion  by 
catching  up  some  such  clue  to  the  disease,  is  often  very  grievously 
in  error. 


48 


CHAPTER  IV.  • 

FEBRILE    DISEASES. 

Div.  I. —  General  Febrile  State. — Fevers — §  1,  Continued  Fever — 
Epidemics —  Cutaneous  Spots — Subdivisions  —  Complications  — 
§  2,  Remittent  Fever — §  3,  Influenza — §  4,  Epidemic  Cholera — 
Its  relation  to  Diarrhoea. 

Div.  II. — Eruptive  Fevers — Measles — Scarlatina  —  Varioloid  — 
Erysipelas. 

Div.  III. — Intermittent  Fevers. 

The  object  -which  we  have  in  view  is  to  direct  the  student  how  to 
proceed  in  the  investigation  of  any  case  submitted  to  him,  in  such 
a  manner  as  may  naturally  lead  to  his  forming  a  correct  judgment 
regarding  its  nature  and  causes.  With  this  purpose  we  have  di- 
rected attention  in  the  preceding  chapter  to  certain  signs  and  symp- 
toms which  have  especial  reference  to  the  general  condition  of  the 
patient,  and  have  endeavoured  to  show  what  conclusions  may  be 
legitimately  drawn  from  these  taken  in  conjunction  with  the  history 
of  the  case.  We  have  also  inquired  what  the  patient  has  to  com- 
plain of.  The  next  step  is  to  take  a  rapid  survey  of  the  various 
organs,  and  also  to  examine  more  closely  any  one  in  which  evidence 
is  given  of  an  abnormal  state  by  the  sensations  of  the  patient,  or 
by  facts  elicited  in  inquiring  into  the  history  of  the  case. 

A  reference  to  the  table  of  diseases  shows,  however,  that  there  is 
a  large  class  in  which  local  disorder,  as  manifested  by  symptoms 
belonging  to  particular  organs,  is  only  secondary  and  subsidiary  to 
the  general  disease.  With  regard  to  such,  the  most  important  facts 
are  those  which  have  a  relation  to  the  general  condition ;  and  while 
the  examination  of  the  various  organs  must  be  by  no  means  omitted, 
the  evidence  which  is  obtained  is  chiefly  negative.  Occasionally 
more  positive  results  are  developed,  and  then  the  examination  must 
be  more  minute.  The  plan  which  I  would  venture  to  recommend, 
is  to  bear  in  mind  the  order  of  arrangement  in  which  the  organs 
are  placed  in  our  table  of  diseases,  and  to  ask  such  general  ques- 
tions regarding  each  in  succession  as  may  lead  to  the  conclusion  that 
they  are  or  are  not  in  a  normal  state.  We  inquire  whether  there  be 
headache,  giddiness,  or  insomnia :  whether  there  be  pain  in  the  chest, 
cough,  shortness  of  breathing,  or  palpitation  ;  sickness,  flatulence, 
&c.  The  care  with  which  this  is  done  must  depend  upon  whether 
the  whole  history  of  the  case  and  category  of  symptoms  correspond 
to  the  special  disease  which  we  are  inclined  to  assume  as  their  cause, 
or  whether  there  be  anything  unusual  or  unaccounted  for  in  the 
notes  of  these  which  have  been  made. 


FEBRILE   DISEASES.  49 

The  first  point  to  be  determined  is  the'  presence  or  absence  of  a 
febrile  state.  The  evidence  of  its  existence  is  derived  from  a  com- 
bination of  general  symptoms,  pointed  out  in  the  early  part  of  the 
preceding  chapter,  taken  in  conjunction  with  a  history  of  a  com- 
paratively recent  origin.  When  symptoms  of  fever  are  present  in 
a  case  of  longer  duration,  its  history  must  be  more  closely  investi- 
gated; because,  on  the  one  hand,  we  may  find  that,  with  a  certain 
amount  of  general  or  local  ailment,  the  patient  has  been  able  to  go 
about  his  usual  avocations  till  within  a  very  short  period,  when 
more  severe  illness  has  set  in  with  rigors,  alternate  flushings,  and 
chilliness,  &c. ;  or,  on  the  other  hand,  we  may  find  that  the  fever  is 
only  an  aggravation  of  long-continued  suffering,  and  caused  by  ex- 
haustion supervening. 

Rigor  is  an  important,  but  not  an  essential,  element  of  febrile 
disturbance;  it  attends  on  the  most  acute  diseases,  but  occasionally 
it  is  not  observed.  When  present,  it  often  serves  to  mark  the 
commencement  of  the  illness,  and  is  therefore  of  value  in  the  his- 
tory of  the  case.  Recurring  frequently  in  the  course  of  the  attack, 
and  described  as  "cold  chills,"  it  is  especially  characteristic  of  con- 
tinued fever.  In  inflammations  it  may  frequently  be  observed  in  a 
severe  form  at  the  outset,  and  then  is  more  commonly  absent  till 
suppuration  commences,  when  the  occurrence  of  rigor  is  very  signi- 
ficant. Its  periodical  recurrence  is  the  chief  distinguishing  feature 
of  ague. 

The  next  point  for  consideration  is,  whether  these  general  symp- 
toms make  up  the  whole  of  the  disease,  or  whether  it  accompanies 
inflammation  of  some  particular  organ;  whether  (to  use  the  hard 
words  of  science)  the  pyrexia  be  idiopathic  or  symptomatic;  and 
this  can  only  be  ascertained  by  the  negative  results  obtained  from 
a  survey  in  detail  of  the  leading  phenomena  connected  with  each 
of  the  various  organs.  A  suspicion  or  guess  may  be  formed  from 
the  circumstance  already  mentioned,  that  when  the  skin  is  hot  and 
dry,  and  the  pulse  feeble  and  frequent,  we  are  more  likely  to  have 
fever  to  deal  with;  and  that  when  the  skin  is  moist,  the  pulse  firm 
and  less  frequent,  the  chances  are  in  favour  of  inflammation.  If 
pain  be  complained  of,  this  may  lead  at  once  to  the  seat  of  the  disease 
when  inflammation  is  present;  but  pain  is  often  absent  in  the  most 
severe  inflammations.  Fever  is  only  accompanied  by  sensations  of 
general  pain  and  uneasiness,  often  spoken  of  a3  "pains  in  the 
bones." 

Pains  in  the  limbs  must  be  localized;  those  which  are  general,  in  the  bones  or 
in  the  muscles,  a  feeling  of  aching  rather  than  pain,  are  the  accompaniments  of 
fever;  those  which  especially  affect  the  joints,  and  are  more  distinctly  painful  and 
tender,  point  rather  to  rheumatism. 

The  essential  element  of  fever  is  so  entirely  beyond  the  reach  of 

our  present  means  of  investigation,  that  its  diagnosis  is  partially 

imperfect.     It  must  be  made  out  to  the  satisfaction  of  the  inquirer 

that  no  local  disease  exists  of  which  febrile  disturbance  is  a  symp- 

4 


FEBRILE    DISEASES. 

i  mi,  and  that  those  local  derangements  which  do  exist,  are  the  legi- 
te  consequences  or  natural  signs  of  the  presence  of  fever  poi- 
son in  the  blood.  Hence,  if  any  local  disorder  lie  present,  of 
which  pyrexia  is  not  a  symptom,  that  must  be  for  the  present  set 
aside  as  not  belonging  to  an  inquiry  into  the  causes  of  fever;  and  if 
no  local  inflammation  be  discovered,  the  febrile  state  must  be  taken 
evidence  of  fever  simply. 

Division  I. — Fevers. 
Fevers  arc  divided  in  the  table  into  three  groups;  two  of  which 
are  characterized  by  well  defined  symptoms  common  to  the  whole  of 
each  group,  viz.,  the  occurrence  of  cutaneous  eruptions,  and  of  regular 
intermissions.  The  remaining  group  which  we  take  first  into  con- 
sideration, has  no  such  common  symptom,  and  to  these  we  have  ap- 
plied the  generic  name  of  fevers.  It  comprises  many  diseases  be- 
longing to  tropical  regions — plague,  yellow  fever,  &c.  We  shall 
consider  those  only  which  are  more  or  less  common  in  this  country. 

§  1.  Continued  Fever. — Accurate  diagnostic  signs,  which  in 
their  totality  give  pretty  sure  evidence  of  other  diseases,  arc  much 
wanting  in  this,  and  many  cases  fall  under  our  observation  of  which 
this  is  especially  true;  a  state  of  general  discomfort,  with  very 
slight  febrile  disturbance,  lasting  only  a  few  days,  in  which  no  dis- 
order of  any  particular  organ  can  be  made  out,  must  necessarily  be 
called  fever,  or  febricula.  At  the  same  time  it  is  quite  certain  that, 
from  ignorance,  or  from  imperfect  examination,  many  cases  are  so 
classed  which  in  reality  belong  to  some  other  genus. 

The  history  of  the  case  may  occasionally  show  that  the  individual 
has  been  placed  in  circumstances  likely  to  engender  fever;  the  fact 
of  a  previous  attack  of  the  same  sort  neither  increases  nor  dimi- 
nishes the  probability  of  the  present  illness  being  fever.  Its  mode 
of  commencement  is  very  various;  either  there  have  been  in  the 
first  instance  some  days  of  weakness  and  depression,  and  undefined 
feeling  of  illness,  followed  by  rigor  or  cold  chilis ;  or  there  has  been 
a  pretty  smart  shivering  to  begin  with,  followed  by  considerable 
heat  of  skin.  Loss  of  appetite  is  invariable,  and  observed  early; 
thirst  is  later  in  its  occurrence,  headache  is  generally  an  early 
symptom,  as  well  as  a  foul  tongue  and  quick  pulse. 

In  reviewing  the  general  symptoms  in  detail,  we  find  that  the 
temperature  of  the  skin  is  generally  elevated,  except  just  at  the 
moment  of  a  rigor,  when  it  is  peculiarly  harsh  and  dry  (cutis  anse- 
rina.)  It  has,  in  the  majority  of  instances,  a  hot  pungent  feeling; 
but  there  are  numerous  exceptions,  in  which  it  is  constantly  or  oc- 
casionally moist,  nay,  whole  epidemics  in  which  it  is  invariably  so. 
The  pulse  is  always  frequent.  This  may  amount  only  to  very  slight 
acceleration,  or  it  may  reach  to  more  than  double  its  ordinary  rate ; 
it  may  be  more  or  less  large,  but  is  always  soft  and  weak,  and  some- 
times very  feeble.     The  tongue  is  invariably  furred  in  the  com- 


FEVER, 


51 


mencement:  subsequently,  in  some  cases,  it  becomes  peeled  and 
chapped,  having  a  tendency  to  be  dry  while  fever  lasts ;  in  other 
cases  the  fur  thickens  and  adheres,  especially  to  the  centre,  leaving 
the  edges  bright  and  red;  in  the  severer  forms  of  the  disease  this 
coating  is  often  brown  or  even  black,  and  sordes  collect  on  the  lips 
and  teeth;  thirst  is  complained  of  in  these  cases  while  conscious- 
ness remains,  and  thus  its  presence  or  absence  may  be  of  good  or 
evil  augury,  as  it  indicates  decrease  of  fever  or  diminution  of  sensi- 
tive perception. 

The  complications  of  fever  as  manifested  in  symptoms  derived 
from  the  different  regions,  and  the  presumption  they  afford  of  its 
existence,  will  be  referred  to  presently;  but  among  the  more  direct 
evidences  of  fever  we  must  regard  the  very  common  occurrence  of  de- 
rangement of  bowels,  as  manifested  in  the  diarrhoea  dependent  on 
enlargement  and  subsequent  ulceration  of  the  follicular  glands  of 
the  intestine.  When  this  is  the  case,  the  appearance  of  the  stools 
greatly  aids  the  diagnosis.  Either  thin  and  ochrey;  or  darker, 
watery  and  mingled  with  curdy  solids ;  or  even  black  and  pitchy, 
from  admixture  with  blood:  they  are  always  highly  offensive. 
Along  with  this  there  is  very  generally  some  tenderness  in  the 
coecal  region,  and  a  gurgling  sensation  communicated  to  the  han# 
on  making  pressure  there.  But  the  circumstance  that  the  motions 
are  nearly  natural  in  appearance,  and  the  existence  of  a  certain 
amount  of  constipation,  must  not  be  taken  as  a  proof  that  the  dis- 
ease is  not  fever.  The  urine  is  generally  scanty,  the  appetite 
always  lost,  and  the  desire  for  fluids  increased. 

Such  are  the  leading  symptoms  of  fever ;  their  varying  intensity 
may  serve  as  a  basis  for  classification,  and  they  are  all  of  much 
importance  in  treatment;  but,  while  no  one  by  itself  is  diagnostic, 
we  observe  that  there  is  some  derangement  of  each  of  those  which 
are  classed  as  general  symptoms.  Some  are  more  important  than 
others,  but  a  perfectly  normal  state  of  any  one  must  put  us  on  our 
guard  in  pronouncing  an  opinion  of  the  existence  of  fever. 

Corresponding  to  the  variations  in  symptoms  there  are  differences 
in  the  intensity  of  the  affection,  from  its  slight  and  transient  form, 
febricula,  to  its  worst  and  most  deadly  shape,  malignant  typhus. 
But,  while  no  two  conditions  can  be  more  widely  separated,  it  is  to 
be  remembered  that  there  are  numerous  intermediate  links  in. regard 
to  severity  and  danger,  which  are  so  closely  allied  together,  and 
pas^by  such  fine  transitions  into  each  other  when  a  large  number 
of  cases  is  examined,  that  no  absolute  line  of  demarkation  can  be 
drawn  between  them. 

There  are  certain  modes  of  division,  which,  so  "far  as  they  con- 
cern diagnosis,  must  here  shortly  be  referred  to.  Thus  there  are 
epidemic,  endemic,  and  ephemeral  fevers.  This  classification  can- 
not be  regarded  as  of  much  practical  value,  as  we  know  not  that  it 
corresponds  to  any  real  difference  in  the  ultimate  nature  of  the 
disease.    We  know  not  whether  an  endemic  fever  may  ever  become 


I 


02  FEBRILE    DISEASES. 

epidemic,  nor  by  what  circumstances  such  a  change  of  character 
can  be  produced.  The  only  importance  of  these  distinctions  is  de- 
rived from  the  observation  that  each  class  presents  for  the  time 
being  certain  peculiarities,  and  the  general  features  of  individual 
examples  have  a  degree  of  resemblance  to  each  other.  It  is  indeed 
surprising  hovr  great  a  similarity  all  cases  of  fever  have  to  each 
other  for  a  given  time  and  in  a  given  place,  and  how  much  they 
differ  from  cases  occurring  at  another  time,  or  in  another  locality. 

1.  Epidemic  fevers,  spreading  probaljly  by  means  of  some  poison  suspended  in 
the  atmosphere,  are  generally  believed  to  possess  the  property  of  communicai 
by  infection;  with  their  specific  characters  the  student  should  make  himself  ac- 
quainted by  observation,  as  soon  as  possible,  whensoever  an  epidemic  begins  to 
prevail. 

2.  Endemic,  or  endemial  fevers,  not  so  clearly  infectious,  but  arising  appa- 
rently from  some  local  influence,  are  generally  found  also  to  present,  in  each  lo- 
cality, distinctive  characters,  which  must  soon  be  familiar  to  a  practitioner  in  any 
given  place. 

3.  Ephemeral  fevers,  breaking  out  quite  unexpectedly,  in  consequence  most 
pr  'bably  of  a  sudden  atmospheric  change,  and  disappearing  with  the  same  rapidity, 
differ  from  the  other  two  chiefly  in  their  being  comparatively  less  severe,  and  com- 
monly marked  by  one  prominent  symptom.     A  very  good  example  may  be  • 

in  the  outbreaks  of  influenza.  To  this  fever  we  have  assigned  a  separate  place  in 
r  classification,  solely  because  its  symptoms  are  so  peculiar,  and  its  occurrence 
frequent. 

Another  mode  of  division  is  that  obtained  from  the  presence  and 
absence  of  cutaneous  eruption,  and  its" special  characters.  If  it  be 
true  that  the  same  cause  cannot  engender  a  fever  with,  and  one 
without  spots,  and  if  it  be  further  true  that  the  same  cause  cannot 
generate  fevers  with  spots  of  dissimilar  kinds,  it  is  plain  that  the 
correct  distinctions  of  fever  spots  would  lead  also  to  the  true  diag- 
nosis of  species  of  fevers.  But  this  is  not  yet  proved.  And,  at  all 
events,  the  absence  of  spots  altogether  neither  warrants  the  con- 
clusion that  the  disease  is  not  fever,  nor  that  it  belongs  to  a  par- 
ticular class  of  which  this  circumstance  may  be  considered  charac- 
teristic. Further,  if  it  be  true  that  these  different  species  of  fevers 
are  prone  to  affect  special  organs  more  than  others,  and  each  species 
a  different  organ,  it  would  be  a  most  valuable  indication  in  treat- 
ment; but  this  is  yet  so  far  uncertain,  that  we  must  receive  the 
probability  with  great  caution,  and  so  much  the  more  closely  in- 
vestigate the  symptoms  appertaining  to  each,  forming  our  judgment 
of  the  character  of  the  fever  from  their  co-existence,  rather  than 
assuming  their  presence  from  the  type  of  fever.  # 

In  a  treatise  on  diagnosis  it  is  obviously  impossible  to  discuss  disputed  points 
in  semeiology,  and  all  that  can  be  done  in  this  place  is  to  point  out  the  different 
characters  the  spots  are  liable  to  present.  In  hospital  practice  the  patient  often 
exhibits,  especially  about  the  neck  and  upper  part  of  the  chest,  a  number  of  mi- 
nute puncta  of  a  blood-stained  appearance,  perfectly  unaffected  by  pressure  with 
the  finger,  and  having  more  or  less  of  a  triangular  shape;  when  once  observed 
they  can  be  easily  recognised  and  distinguished.  They  are  merely  flea-bites,  but 
they  have  this  value  in  diagnosis,  which  is  often  overlooked,  that  the  accompany- 
ing ecchymosis  indicates  depressed  vitality.  The  true  fever  spots  present  three 
varieties,  each  of  which  may  be  miugled  with  petechiae. 


FEVER.  53 

1.  A  very  copious,  dusky,  purplish-coloured  rash,  which  often  accompanies  epi- 
demic typhus.  A  patient  "is  found  with  rather  a  dusky  colour  of  face,  depressed 
countenance,  listless,  or  even  partially  unconscious  expression,  eyes  suffused, 
tongue  dry  and  brown,  with  a  thick  crust  on  the  centre,  lips  and  teeth  covered 
with  sQrdes,  skin  dry  and  hot,  but  not  pungent  (the  vitality  being  so  much  de- 
pressed;) his  pulse  is  quick  and  weak,  and  his  movements  are  few  and  tremulous, 
or  accompanied  by  subsultus.  In  such  a  case,  if  the  skin  of  the  abdomen  and 
thorax  be  inspected,  it  will  very  often  be  found  covered  with  a  mottled^measly- 
shaped  rash  of  a  purplish  or  mulberry  colour,  with  no  perceptible  elevation,  and 
of  more  or  less  persistence  under  pressure  with  the  finger,  becoming  fainter,  but 
not  disappearing  altogether;  and,  in  the  worst  cases,  passing  into  or  mingled  with 
ecchymosed  spots,  which  are  wholly  unaffected  by  pressure,  in  the  latter  case 
the  colouring  matter  has  actually  become  extravasated  as  in  purpura,  and  to  this 
the  name  of  petechia?  is  applied ;  in  the  former  there  is  merely  a  retardation  or 
stoppage  of  dark-coloured  blood  in  the  cutaneous  capillaries. 

2.  Perhaps  in  an  earlier  stage  of  the  same  case,  or  in  a  similar  case,  when  the 
fever  is  not  epidemic,  this  general  rash  is  not  seen;  but  there  are  numerous  dis- 
tinct, rounded,  scarcely  elevated  spots,  not  so  dark,  of  a  crimson  colour,  with  a 
similar  character  of  persistence,  not  wholly  disappearing  under  the  finger.  Oc- 
casionally one  or  two  of  these  may  put  on  a  blacker  colour,  and  become  altogether 
persistent  by  ecchymosis. 

These  two  classes  mingle  with  each  other. 

3.  A  third  sort  of  fever  spots  occurs  in  cases  more  commonly  of  an  endemic 
kind,  in  which  there  is  much  less  general  depression,  rarely  suffusion  of  eyes  or 
congestion  of  face;  subsultus  is  less  frequently  seen,  the  movements  may  be  tre- 
mulous, but  there  is  much  less  apathy  and  listlessness.  The  skin  is  hot  and  pe- 
culiarly pungent;  the  pulse,  more,  or  less  quick,  is  not  so  feeble;  tke_tongue,_pre- 
senting  at  first  very  red  edges,  soon  becomes  peeled  in  the  centre,  is  sometimes 
chapped,  raw,  and  glossy,  or,  occasionally,  with  a  dry^thin  crust  over  the  abraded 
mucous  membrane — perhaps  it  is  evenly  and  thinly  coated,  or  has  a  patchy  ap- 
pearance, according  to  the  condition  of  the  intestinal  tract;  diarrhoea  is  frequently 
present,  and  in  such  cases,  when  spots  are  found,  they  are  few  in  number,  three 
or  four  over  the  abdomen,  rounded,  slightly  elevated,  of  a  pink  or  rose  colour,  and 
disappearing  entirely  under  the  finger^but  returning  rapidly  as  soon  as  the  pres- 
sure is  removed. 

These  are  generally  of  small  size,  but  may  sometimes  be  considerably  larger 
than  those  already  described  as  dusky  spots ;  occasionally,  too,  they  are  much 
more  numerous,  and  the  colour  becomes  deeper;  they  then  assume  some  degree 
of  persistence,  but  are  very  rarely,  if  ever,  associated  with,  or  transformed  into, 
ecchymosis.  By  some  mistake  of  nomenclature,  these  spots,  and  the  fever  they 
accompany,  have  been  called  typhoid  (resembling  typhus,)  because  the  symptoms 
of  typhus  are  in  great  measure  wanting.  The  term  typhoid  ought  to  be  restricted 
to  symptoms  resembling  typhus,  in  diseases  of  heterogeneous  type,  not  to  homo- 
geneous diseases  with  distinctive  characters. 

4.  Petechial  spots  may  occur  towards  the  close,  with  no  previous  rash. 

5.  In  addition  to  these  spots,  we  observe  that  some  epidemics  are  accompanied 
by  miliary  eruption,  when  there  is  copious  diaphoresis;  just  as  so  often  hap 

in  rheumatic  fever.  They  have  this  general  relation  to  the  others,  that  perspira- 
tion is  necessary  to  their  development,  and  appears  to  be  opposed  to  the  existence 
of  true  fever  spots. 

Of  this  classification  it  is  most  important  to  note  that  there  is  no 
character  of  disease  with  spots  of  any  one  of  the  forms  noticed, 
that  may  not  have  its  exact  counterpart  in  a  case  where  there  are 
no  spots  at  all.  But  the  student  must  work  out  for  himself  the 
question  whether  there  he  any  specific  virus  that  produces  one  ap- 
pearance or  the  other,  as,  in  fact,  their  cause  is  yet  quite  undeter- 
mined. The  coincidence,  when  they  are  present,  is  of  great  value 
in  diagnosis ;  for  it  does  not  as  yet  appear  that  they  are  ever  seen 


54  FEBRILE    DISEASES. 

in  any  other  condition  except  that  which  we  express  by  the  term 
fever.  Whatever  light  may  be  thrown  by  future  investigation  upon 
ir  relation  to  internal  organs,  whether  the  hypothesis  of  two  dis- 
tinct fevers  be  confirmed  or  rejected,  it  is  quite  certain,  from  long- 
continued  observation,  that  ulceration  of  the  bowels  seldom  goes 
along  with  copious  cutaneous  eruption. 

Another  classification  is  derived  from  the  prominent  symptoms 
in  the  majority  of  the  cases  which  occur  simultaneously,  and  fever 
is  spoken  of  as  fever  with  head  symptoms,  fever  with  chest  symp- 
toms, and  fever  with  abdominal  symptoms.  The  name  in  most 
common  use,  both  in  this  country  and  abroad,  in  connexion  with 
division,  is  gastric  fever,  or  abdominal  typhus. 

This  brings  us  to  the  complications,  symptomatic  or  simply  con- 
comitant of  fever.  The  prominent  feature  of  the  disease  must 
never  be  lost  sight  of — that  it  is  not  inflammatory.  The  blood  is 
in  a  state  of  depressed,  not  exalted  vitality.  This  is  exhibited  by 
lassitude  and  weakness,  great  in  proportion  to  heat  and  dryness  of 
skin,  and  by  feebleness  of  pulse,  increasing  in  the  ratio  of  its  fre- 
quency ;  it  is  a  condition  of  asthenic  pyrexia,  in  opposition  to  in- 
flammatory fever,  or  sthenic  pyrexia. 

Local  congestions  occur  in  its  course ;  and  in  consequence  of  the 
irritation  thus  caused,  a  sort  of  inflammatory  action  may  be  pro- 
duced. In  the  peritoneum  there  may  be  actual  inflammation  in 
consequence  of  ulceration  or  perforation  of  the  bowel;  but  these 
secondary  actions  are  not  of  the  elements  of  fever. 

a.  In  the  head  we  have  delirium,  insomnia,  unconsciousness,  coma. 
That  these  are  not  due  to  inflammation  is  proved  by  the  history  of 
the  case.  They  have  been  gradually  developed,  beginning  with 
restlessness  at  night,  occasional  muttering  at  that  time,  with  perfect 
consciousness  by  day;  there  has  been  no  intolerance  of  light;  the 
headache  is  diffused  and  general;  the  pupils  have  not  been  early 
contracted ;  the  symptoms  have  only  attained  in  the  later  stages  to 
their  maximum,  and  even  then  they  still  continue  to  be  much  more 
marked  at  night;  they  are  accompanied  by  listlessness  and  depres- 
sion, as  opposed  to  excitement.  Deafness  is  a  very  common  condi- 
tion in  severe  cases  of  fever,  sometimes  persisting,  more  or  less, 
during  the  whole  period  of  recovery.  It  would  seem  to  be  only 
one  expression  of  the  general  obtuseness  of  all  the  senses,  which  is 
often  so  remarkable. 

b.  In  the  lungs  congestion  almost  always  comes  on  more  or  less 
from  position,  and  especially  in  those  cases  where  the  blood  is  most 
altered  in  character.  This  is  not  true  pneumonia;  it  only  degene- 
rates into  low  inflammation  in  consenuence  of  the  stagnation  of 
t!ie  blood  in  the  pulmonary  capillaries.  Here,  too,  the  history  points 
out  that  cough  and  rusty  sputa  have  not  been  the  early  indications 
of  the  attack,  but  have  supervened  during  its  continuance.  A 
condition  of  the  mucous  membrane  allied  to  that  of  the  skin  in 
fever  may  produce  a  certain  amount  of  bronchitis.    This  sometimes 


FEVER.  00 


occurs  early;  but  it  will  be  remarked  that  the  febrile  state  is  far 
greater  than  any  that  experience  teaches  us  can  be  caused  by 
bronchitis,  however  acute;  in  addition  to  which,  the  febrile  state 
accompanying  acute  bronchitis,  when  it  depends  on  an  inflammatory 
condition  of  the  membrane,  is  sthenic;  that  of  fever  itself  is  essen- 
tially asthenic.  The  combination  of  fever  and  bronchitis,  bearing 
the  name  of  influenza,  will  be  noticed  afterwards. 

c.  There  may  be  tension  and  tenderness  of  the  abdomen.  Here 
we  have  quite  a  different  class  of  phenomena;  for  ulceration  of  the 
intestines  is  peculiarly  a  concomitant  of  fever — not  in  every  case, 
but  in  so  large  a  number  of  instances  as  to  show  that  the  affection 
of  the  mucous  glands  of  the  bowel — which,  if  unchecked,  pas 
into  ulceration — is  a  primary  morbid  state  in  certain  forms  of  this 
disease.  In  some  instances  it  would  appear  that,  when  other  vital 
organs  are  more  severely  implicated,  the  poison  remains  in  a  qui- 
escent state;  and  after  death  merely  elevated  prominent  patches  of 
glands  are  found,  while  in  other  instances  they  rapidly  run  into  a 
state  of  ulceration.  Of  this  phenomenon  it  is  still  more  true  than 
of  the  passive  congestions  already  noticed,  that  subsequently,  a 
condition  of  real  inflammation  of  a  low  type  occurs;  in  fact,  ul- 
ceration is  itself  an  action  of  this  kind;  and  as  it  extends  to  th< 
other  coats  of  the  bowel,  and  especially  the  peritoneal  covering,  the 
symptoms  become  more  and  more  closely  allied  to  abdominal  inflam- 
mation. 

In  its  earlier  stage  the  state  of  the  stools  shows  the  tendency  to 
ulceration;  and  after  a  very  short  time  slight  tenderness  comes  on. 
which  may  be  soonest  detected  in  the  right  iliac  fossa — often  not 
noticed  by  the  patient,  not  complained  of,  and  not  produced  by 
slight  handling,  but  shown  to  exist,  when  gentle,  firm,  deep  pressure 
is  made,  by  its  causing  a  pinching  of  the  features,  and  transient 
expression  of  anxiety,  accompanied  by  a  gurgling  sensation.  Sub- 
sequently great  tympanitic  distention  occurs  from  loss  of  muscular 
contractility,  which  is  an  evidence  of  more  decided  inflammatory 
action;  and  this  may  pass,  by  almost  unnoticed  gradation,  into 
peritonitis,  or  may  end  in  sudden  rupture  and  extravasation  of  the 
bowel  contents.  The  tongue,  as  already  noticed,  shows  in  such 
circumstances  a  tendency  to  peel,  especially  along  the  centre ;  it 
becomes  red  and  shining,  often  dry  at  the  same  time,  and  subse- 
quently, chapped,  aphthous,  ulcerated. 

It  would  appear  that  this  state  of  tongue  is  sometimes  unaccompanied  by  other 
general  symptoms  of  ulceration  of  the  bowels,  and  is  not  always  present  when  we 
believe  ulceration  to  be  going  on.  It  seems  to  depend  on  a  general  cause,  affect- 
ing most  commonly  the  whole  mucous  tract,  at  least  as  far  as  the  ilio-ccecal  valve. 
but  sometimes  more  limited  and  local.  The  one  coudition  is  not  to  be  presumed 
to  be  derived  from  the  other. 

The  fieces  in  this  condition  are  thin,  watery,  curdy ;  sometimes 
of  an  ochrey  colour,  often  very  dark,  and  occasionally  pitchy,  from 
the  presence  of  blood  derived  from  an  ulcerated  surface;  always 


5G  FEBRILE    DISEASES. 

fetid  and  offensive.    When  consistent  or  natural  in  appearance,  we 

-  be  sure  that  ulceration  is  not  going  on. 

.  In  addition  to  the  severe  kinds  of  bowel  ailment  accompanying 
one  of  the  more  intense  and  well-marked  forms  of  fever,  an  allied 

lit  ion  is  found  in  milder  cases,  or  what  may  be  termed  febricula, 
ing  of  irritation  of  the  mucous  membrane,  which  may  show 

If  in  sore  throat,  or  in  gastric  pain  and  tenderness,  or  in  diar- 
rhoea.    In  all  these  conditions  the  distinction  to  be  drawn  between 

;1  disorder  per  se,  and  such  disorder  arising  out  of,  and  accom- 
panying a  general  state,  must  be  arrived  at  simply  on  the  principles 
already  pointed  out — first,  febrile  disturbance,  out  of  all  proportion 
to  the  "local  disorder;  second,  its  character  being  asthenic,  as  op- 
posed to  inflammatory  fever.   . 

The  character  of  the  fevers  of  the  present  day  most  unquestion- 
ably tends  towards  debility;  and  we  rarely  find  a  pulse  that  has 
even  any  degree  of  hardness,  never  one  that  suggests  the  propriety 
of  bleeding;  the  powers  of  life  are  wholly  prostrated,  the  nervous 
centres  are  partially  insensible  to  impressions  from  without,  are 
unable  to  exert  steady  muscular  movement  by  energetic^  stimulus 

tn  within.  But,  if  we  trust  the  observation  of  men  of  judgment 
and  experience  who  have  preceded  us,  it  was  not  always  so ;  and  at 
some  future  period  the  disease  may  again  put  on  a  more  inflamma- 
tory character. 

The  bowel  complication  so  often  seen  has  been  a  subject  of  considerable  con- 
troversy of  late  years,  with  reference  to  the  question  of  what  circumstances  deter- 
mine its  presence  or  absence.     By  the  Vienna  school  it  is  asserted,  that  a  typl 
lent  exists  which  finds  its  outlet  either  by  this  or  by  other  channels:  and,  it  is 
I  that,  when  typhous  pneumonia  or  bronchitis  exists,  typhous  exudation  in 
itinal  glands  is  more  commonly  absent.     The  French  school,  to  whom  we 
owe  the  name  of  typhoid,  assumes  the  existence  of  two  distinct  diseases,  as  repre- 
7  typhus,  and  typhoid  fevers.     To  this  has  been  added  the  distinction  of 
'ready  alluded  to,  which  are  supposed  to  be  diagnostic  of  each. 
These  subjects  afford  scope  for  the  observation  of  the  student,  and,  ere  long, 
bably  be  definitively  settled.     For  the  present,  I  would  warn 
unjustifiable  confidence  in  any  theory,  and  rcmhid  him  that  the  i 
of  importance  in  regard  to  the  immediate  treatment  of  any  case  is  not  which 
I      .rv  he  shall  adopt,  but  what  phenomena  are  actually  present,  and  may 

best  m  ■  t  them  by  suitable  treatment;  whether  there  be  congestion  of  the  h 
or  ulceration  of  the  bowels,  not  whether  he  has  got  typhus  or  typhoid  fever  to  deal 
with. 

All  the  complications  alluded  to  are  apt  to  be  overlooked  or  forgotten  in  the 
consideration  of  the  existence  of  fever,  and  yet  they  are  each  of  greater  or  less  im- 
portance in  treatment.  And  again,  while  exact  knowledge  of  their  true  character 
i  sntial  in  arriving  at  the  very  important  negative  conclusion,  that  inflamma- 

tion of  some  particular  organ  does  not  exist,  their  very  presence  becoi  addi- 

1  corroboration  of  the  belief,  that  wc  have  to  do  with  a  case  of  continued  fever. 

Under  the  general  head  of  fever  there  are  also  classed,  in  the 
table  of  diseases,  remittents,  influenza,  and  epidemic  cholera. 

§  2.  The  name  of  remittent  fever  is  applied  to  a  disease  peculiar 
to  warm  climates.  It  is  now  very  generally  believed  to  be  only 
typhus  as  modified  by  atmospheric  influences  and  the  condition  of 


INFLUENZA. 


57 


the  nervous  and  sanguiferous  systems  of  Europeans  residing  in 
tropical  latitudes.  The  same  analogy  holds  with  reference  to  the 
only  fever  of  this  type  ever  seen  among  ourselves — infantile  remit- 
tent. 

The  excitable  frame  of  childhood  portrays  more  vividly  the  ex- 
acerbations and  remissions  which,  even  in  adult  age,  are  in  greater 
or  less  degree  observable  in  a  case  of  continued  fever ;  and  in  them 
the  remission  becomes  so  marked,  that  for  a  time  the  disease  seems 
almost  to  be  gone.  In  truth,  the  prominence  of  this  one  symptom 
is  no  sufficient  reason  for  separating  this  disease  from  the  endemic 
fever  of  adults ;  and  there  is  nothing  to  show  that  infantile  remit- 
tent may  not  arise  even  from  the  infection  of  typhus.  The  great 
question  in  diagnosis  is,  how  to  distinguish  this,  generally  one  of 
the  more  unimportant  diseases  of  infancy,  from  the  much  more 
dangerous  malady  known  as  acute  hydrocephalus.  The  same  rule 
must  be  followed  as  in  the  study  of  continued  fever  in  adults ;  our 
conclusion  must  rest  more  on  negative  than  on  positive  evidence. 
We  have  positive  evidence  of  an  acute  febrile  disease ;  we  seek  for 
negative  evidence  that  there  is  not  inflammation  of  the  head,  the 
chest,  or  the  abdomen.  The  investigation  of  these  points  will 
occupy  our  attention  at  a  future  period;  and  in  the  consideration 
of  acute  hydrocephalus  reference  will  be  made  to  the  points  of 
resemblance  and  difference,  in  so  far  as  they  can  throw  light  upon 
the  discrimination  of  these  two  diseases,  which  are  unfortunately 
often  mistaken  for  each  other. 

§  3.  Influenza. — This  disorder  is  characterized  by  an  irritation 
or  inflammatory  condition  of  the  mucous  membrane  of  the  lungs, 
implicating  also  that  of  the  nares  and  the  conjunctiva ;  but,  super- 
added to  this,  and  constituting  its  essential  feature,  is  the  lassitude 
and  exhaustion  of  fever.  A  common  catarrh,  or  an  attack  ^  of 
bronchitis,  it  is  now  the  fashion  to  call  influenza.  In  scientific 
diagnosis  they  ought  to  be  distinguished ;  still,  cases  must  occur  in 
which  these  different  diseases  so  merge  into  each  other,  as  to  render 
it  difficult, *or  even  impossible.  Thus,  in  an  enfeebled  constitution 
the  least  disturbance  may  provoke  symptoms  of  general  derange- 
ment, with  fever  of  an  asthenic  type,  closely  allied  to  influenza; 
exactly  as  more  severe  disease  may  in  the  same  constitutions  cause 
typhoid  symptoms,  or  symptoms  resembling  typhus.  The  determi- 
nation will  be  much  aided  by  observing  whether  the  attack  occur  as 
a  solitary  instance,  or  whether  similar  case3  are  numerous  at  the 
same  time. 

It  is  unnecessary  to  enter  much  into  detail,  with  regard  to  the  history  and  the 
ptoms.  Whatever  is  true  of  common  continued  fever  in  its  milder  form,  is 
likely  to  be  true  of  this  disorder,  bearing  in  mind  the  great  distinction,  that  in  the 
one  the  mucous  membrane  of  the  bowels  is  the  subject  of  a  peculiar  affection,  and 
in  the  other  the  mucous  membrane  of  the  lungs  is  the  principal  seat  of  morbid 
action.  The  history  points  out  its  recent  commencement,  even  when  supervening 
up  n  previous  ailment.    The  general  symptoms  indicate  a  febrile  state;  the  aspect 


58  FEB KILE   DISEASES. 

of  llio  patient  is  more  or  less  depn  ied;  hia  sensations  lead  him  to  complain  of  a 
sense  of  lassitude  and  general  discomfort,  and  of  cough,  tightness  of  chest,  &c., 
siM.li  as  are  usually  present  in  catarrhal  affection.  The  chest  symptoms  are  those 
of  acute  bronchitis. 

Influenza  differs  from  continued  fever  with  superadded  bronchitis,  chiefly  in  the 
greater  prominence  of  the  symptoms  of  irritation  of  the  mucous  membrane  of 
lungs,  and  the  affection  of  the  nose  and  eyes,  as  well  as  in  the  comparatively 
milder  character  of  the  fever;  but  this  is  often  only  a  question  of  degree. 

§  4.  Epidemic  Cholera. — This  frightful  disorder,  which  has 
come  to  us  from  the  tropics,  and  has  visited  us  so  frequently  of 
late  years,  is  classed  among  the  fevers,  chiefly  on  account  of  the 
increasing  conviction  that  it  is  one  of  the  acute  blood  diseases,  and 
the  evident  febrile  reaction  after  recovery  from  the  stage  of  col- 
lapse. It  must  be  admitted,  however,  that  in  very  many  instances 
the  fever,  as  such,  is  very  slight  in  intensity,  as  compared  with  the 
previous  depression;  in  others  it  is  a  formidable  event,  and  not  un- 
lVcMjuently  the  cause  of  the  fatal  termination.  One  characteristic, 
which  must  not  be  lost  sight  of,  is  its  epidemic  influence;  though 
we  cannot  exactly  trace  the  manner  of  its  propagation,  it  clearly 
follows  the  general  laws  of  all  epidemics — such,  for  example,  as  ty- 
phus, the  commonest  and  best  known  of  those  of  this  country. 

The  history  of  the  case  may  ultimately  be  the  means  of  our 
learning  its  mode  of  propagation,  as  it  has  already  served  to  de- 
termine that  its  cause  is  not  simply  an  atmospheric  influence  float- 
ing about  over  our  heads.  In  diagnosis  it  is  of  little  service,  except 
so  far  as  it  may  preserve  us  from  paying  too  much  regard  to  the 
presence  of  collapse,  as  indicating  cholera,  when  there  is  any  other 
antecedent  cause  of  exhaustion.  Collapse  is,  in  reality,  only  an 
accident,  which  may  co-exist  with  any  condition  of  extreme  de- 
pression— e.  g.,  the  colliquative  diarrhoea  of  phthisis. 

The  general  symptoms  in  the  commencement  of  cholera  are  very 
different  from  those  commonly  seen  in  fever.  The  skin  is  cold  and 
clammy;  the  pulse  feeble  and  not  frequent;  the  tongue  cold,  moist, 
and  not  much  coated;  the  stools  remarkably  copious,  pale,  and  free 
from  odour;  the  urine  suppressed;  there  is  almost  always  severe 
vomiting;  and  the  want  of  appetite  and  thirst  are  such *s  naturally 
result  from  the  excessive  discharges  from  the  whole  course  of  the 
alimentary  canal.  As  the  disease  proceeds  to  collapse,  these  symp- 
toms increase  in  intensity,  the  coldness  of  the  skin  and  its  blue- 
ness  or  lividity  become  most  striking;  the  pulse  probably  imper- 
ceptible; and  the  stools  and  vomit  assume  the  characters  of  a  thin, 
colourless  fluid,  resembling  rice  water.  In  reaction  the  skin  is 
often  very  long  in  regaining  its  temperature,  and  is,  perhaps,  never 
hot  and  dry,  as  in  ordinary  fever;  the  tongue  becomes  dry  and 
more  coated;  the  pulse  returns,  and  is  frequent  and  feeble;  the 
diarrhoea  ceases;  thirst  abates;  and  in  favourable  cases  the  urine, 
at  first  scanty  and  albuminous,  is  gradually  restored  to  its  normal 
condition.  If  this  event  do  not  occur  soon  after  reaction  is  esta- 
blished, the  issue  will  probably  be  unfavourable. 


EPIDEMIC    CHOLERA.  59 

The  aspect  of  the  patient  is  depressed,  and  the  expression  listless, 
and  there  is  a  remarkable  appearance  about  the  eyes,  which,  during 
the  existence  of  epidemic  cholera,  has  often  served  to  warn  myself 
and  others  that  an  attack  of  diarrhoea  would  proceed  to  the  more 
fully  developed  disease.  It  is  hard  to  describe  in  words;  but  con- 
sists of  hollowness  of  the  orbits  and  sinking  of  the  eye,  with  a 
leaden  colour  around,  and  a  listlessness  of  expression.  The  colour 
of  the  skin  first  assumes  an  earthy  hue,  subsequently  passing  into 
complete  lividity,  which  lasts,  especially  on  the  hands,  during  the 
greater  part  of  the  stage  of  the  reaction. 

The  patient  makes  little  complaint  of  pain,  except  that  de- 
pendent on  cramps.  By  some  the  occurrence  of  cramp  is  regarded 
as  the  symptom  which  distinguishes  cholera  from  simple  vomiting 
and  purging:  it  is  simply  an  accident;  a  very  common  one  truly, 
but  one  which  may  not  occur  in  real  cholera,  and  may  be  present 
when  the  case  is  Unequivocally  not  cholera.  There  is  no  complaint 
of  nausea,  though  the  constant  and  urgent  vomiting  can  scarcely 
be  supposed  to  exist  without  it ;  there  is  also  no  complaint  of  pain 
with  the  purging:  th»  sensations  no  doubt  are  blunted;  but  this 
painlessness  is  an  important  feature  in  the  case,  and  it  may  even 
excite  surprise  on  the  part  of  the  patient  himself,  that  such  enor- 
mous discharges  take  place  from  the  stomach  and  bowels,  when  he 
has  so  little  feeling  of  internal  derangement.  In  the  beginning  of 
an  attack,  the  existence  of  diarrhoea  without  pain  or  griping,  will 
cause  the  medical  attendant  to  be  on  the  alert;  but,  unfortunately, 
it  has  just  the  opposite  effect  with  the  patient,  who  cannot  fancy 
that  anything  is  seriously  wrong  when  he  has  so  little  feeling  of  dis- 
comfort. Another  remarkable  feature  is  the  sensation  of  burning 
heat  and  oppression  so  often  complained  of,  while  the  skin  is  cold 
and  corpse-like;  the  patient  obstinately  resists  every  attempt  to 
raise  the  temperature  by  artificial  means,  and,  in  the  restlessness  of 
the  disease,  throws  off  the  warm  blankets  in  which  he  is  wrapped. 

Among  particular  symptoms  are  ranked  the  change  of  the  natu- 
ral sound  of  the  voice  into  a  hoarse  whisper,  the  vox  choleraica ; 
and  the  circumstance  of  the  tongue  and  the  breath  being  sensibly 
cold  to  the  hand  of  the  observer.  These  facts  may  be  interesting 
in  any  particular  case,  but,  as  they  belong  to  the  accidents  of  the 
disease,  they  must  not  be  elevated  into  diagnostic  symptoms. 

The  mental  faculties  are  not  obscured  till  an  advanced  period, 
when  the  pupils  become  contracted,  the  brain  oppressed,  and  the 
patient  comatose.  Prior  to  this,  there  is  only  a  condition  of  rest- 
lessness of  body  and  inactivity  of  mind. 

Dunne  the  existence  of  an  epidemic  cholera  there  can  be  no  difficulty  in  classi- 
fying the°cases  which  present  well-developed  features  of  the  disease  ;  but  its  march 
is  attended  by  coincident  diarrhoea,  and  there  is  in  reality  no  definite  boundary 
between  the  one  and  the  other.  Every  link  is  filled  up  by  cases  of  varying  in- 
tensity, from  the  very  worst  of  cholera  to  the  mildest  of  diarrhoea.  The  indications 
by  which  we  are  guided,  the  characters  of  the  evacuations,  the  existence  of  cob 
-e,  and  the  suppression  of  urine,  are  not  directly  connected  with  the  essence  of 


CO  FEBRILE   DISEASES. 

and  <lo  not  show  where  the  lino  is  to  be  drtiwn.    Hei         '   that  one 
records  a  smaller  mortality  than  another,  because  he  includes  a  larger 
-  of  cases;  and  that  the  same  treatment  appears  to  be  followed  by  such  vary- 
ing success  in  different  ban     . 

We  have  found  the  same  obscurity  in  attempting  to  discriminate  different  classes 
of  fever.     But,  while  we  cannot  yet  feel  certain  whether  they  arise  IV'  ame 

or  from  different  causes,  we  have  this  remarkable  difference  between  Asiatic  cho- 
lera and  sporadic  or  English  cholera,  that  the  one  travels  to  us  from   the  tropics, 
its  rise  in  temperate  climates,  while  the  other  occurs  every  year 
•Ives.     On  the  other  hand,  just  as  during  the  presence  of  an  epidemic 
of  typhus,  there  is  extreme  difficulty  in  distill  ;  cases  dependent  on  the  epi- 

lic  influence  from  those  naturally  springing  from  endemial  causes,  which  might 
have  equally  occurred  during  its  absence;  so  during  an  epidemic  of  cholera,  there 
is  often  much  difficulty  in  recognising  a  case  of  simply  severe  diarrhoea.     In  the 
one  case  or  the  other  the  distinction  is  only  based  on  the  totality  of  the  sym|  toms, 
sing  it  rather  under  one  denomination  than  the  other;  and  until  we  know  some- 
thing more  of  the  real  nature  of  the  disease,  we  must  not  forget  to  give  its  due 
to  the  a  priori  argument  of  its  uuiversality  and  its  transmission  from  one 
<on  to  another.     In  my  own  experience  I  have  found  that,  when  a* 
has  been  given  to  this  point,  distinctive  characters  have  been  observed  which 
would  otherwise  have  escaped  notice. 

Division  II. — Eruptive  Fevers. 

This  class  includes  in  our  table  of  diseases  four  distinct  forms: — 
1,  measles;  2,  scarlatina;  3,  varioloid  eruptions;  4,  erysipelas. 

There  may  be  much  difficulty  in  deciding  whether  a  case  present- 
ing itself  with  the  general  characters  of  fever,  may  not  terminate 
in  some  cutaneous  eruption.  The  probability  is  to  be  learned  from 
the  chances  of  exposure  to  infection,  and  also,  in  some  measure, 
from  the  suddenness  of  the  attack.  The  appearance  of  the  erup- 
tion soon  determines  the  point,  and  often  has  shown  itself  before 
the  amount  of  febrile  disturbance  has  been  such  as  to  call  for  medi- 
cal aid.  It  is  of  importance  to  avoid  mistakes  in  such  matters, 
because  an  early  isolation  of  the  sufferer  may  prevent  the  spread 
of  the  malady  to  other  members  of  the  family,  and  blame  greatly 
uisproportionefl  to  the  extent  of  the  oversight  is  always  awarded  to 
the  attendant  who  has  not  foreseen  the  possibility  of  the  occurrence. 

In  8ase  of  a  sudden  attack,  the  age  of  the  patient  has  some  bear- 
ing on  the  possibility  of  eruptive  fever,  because  so  large  a  propor- 
tion of  these  cases  occur  in  early  life.  Inquiry  ought  to  be  made 
whether  the  patient  have  previously  suffered  from  measles  or  scar- 
latina, and  whether  he  be  protected  from  smallpox  by  vaccination 
or  not. 

Children  suffer  more  frequently  from  most  of  these  fevers  than  adults.     An  at- 
tack of  measles  is  rare  after  puberty,  because  so  few  persons  pass  through  the  pe- 
riod of  childhood  without  suffering  from  this  disorder,  and  its  recurrence  is  not  a 
-non  event.     The  liability  to  scarlatina  seems  to  be  very  greatly  diminished  in 
adult  age.     Unvaccinated  children  are  especially  liable  to  smallpox  if  at  all  ex- 
1  to  its  contai;iou;  after  vaccination  the  liability  again  increases  as  age  ad- 
:es,  from  twelve  or  fifteen  up  to  twenty-five  or  thirty.     Both  in  the  i 
and  unmodified  forms  a  first  attack  of  smallpox  may  occur  at  any  period  of  life, 
but  is  very  mi  common  after  the  age  of  thirty.     Second  of  all  tl 

are  unusual,  but  exceptions  are  sometimes  met  with.  Erysipelas,  on  the 
other  hand,  is  not  a  disease  of  childhood,  and  does  not  in  any  way  guard  the  sys- 
tem against  a  second  attack. 


ERUPTIVE   FEVERS.  Gl 

The  period  of  the  illness,  when  the  case  is  first  seen,  greatly  aids 
in  determining  whether  it  may  be  one  of  eruptive  fever  or  not,  for, 
after  three  or  four  days,  the  chances  of  scarlatina  or  smallpox  are 
almost  gone — the  eruption  of  measles  is  sometimes  deferred  to  the 
sixth  day  of  the  fever;  but  these  are  the  extremes,  as  the  eruption 
is  generally  seen  earlier.  Definite  rules  are  laid  down  in  books ; 
but  these  will  be  found  in  practice  to  be  very  frequently  deviated 
from,  if  the  history  given  by  the  friends  or  the  patient  himself  be 
true.  * 

In  the  preliminary  stage,  the  general  symptoms  are  such  as  indi- 
cate a  more  active  or  sthenic  type  of  fever  than  those  which  are  not 
attended  with  cutaneous  eruption ;  the  skin  is  hot,  and  the  pulse 
firm,  and  there  is  less  of  lassitude  and  depression.     Cases  of  simple 
continued  fever  sometimes  present  similar  symptoms  in  the  early 
stage,  and  this  may  be  accompanied  by  some  general  redness  of  the 
skin,  which  is  then  apt  to  be  regarded  as  the  precursor  of  eruptive 
fever ;  it  is,  so  far  as  we  know,  only  accidental,  and  the  progress  of 
the  case  can  alone  determine  its  nature.     On  the  other  hand,  in 
some  of  the  very  worst  forms  of  scarlet  fever,  the  general  symptoms 
put  on  a  typhoid  type ;  and  then  the  cutaneous  eruption  is  scanty, 
or  may  be  even  altogether  absent;  the  depression  is  great,  and  the 
whole  system  seems  overpowered  by  the  poison.     Less  frequently 
an  analogous  condition  is  met  with  in  smallpox,  with  this  difference, 
that  the  cutaneous  eruption  is  excessive  in  the  early  stage,  but  the 
constitution  of  the  patient  has  not  power  fully  to  develop  it;  when 
antecedent  blood-disease  leads  in  such  cases  to  the  formation  of  pe- 
techia, the  diagnosis   is  very  obscure.      Suppression  of  measles 
seems  to  have  more  to  do  with  the  co-existence  of  internal  inflam- 
mation, than  with  the  power  of  the  miasmatic  poison. 

The  period  of  incubation,  as  it-  is  called,  has  no  distinct  charac- 
ters. During  the  incursion  of  the  fever,  before  any  cutaneous  erup- 
tion has  appeared,  there  are  certain  indications  which,  more  or  less 
definitely,  point  to  what  is  about  to  occur: — 1.  In  measles,  it  is  at- 
tended with  coryza.  2.  In  scarlatina,  there  is  sore  throat,  and  the 
appearance  of  the  tongue  is  peculiar.  3.  In  varioloid  eruptions, 
paiu  in  the  back  is  present.  4.  Erysipelas  is  not  marked  by  any 
special  prodromata;  there  is  a  general  sense  of  malaise,  sometimes 
sore  throat,  and,  not  unfrequently,  a  dull,  aching  pain,  or  pricking 
sensation,  in  the  part  that  is  to  be  attacked. 

1.  Coryza  belongs  also  both  to  common  catarrh  and  to  influenza.  In  the  for- 
mer there  is  much  less  fever;  in  the  latter,  if  the  fever  be  equal,  it  is  accompanied 
by  much  more  of  depression.     The  affection  of  the  mucous  membrane  in  measles, 

.cially  leads  to  injection  of  the  conjunctivae;  in  catarrh  and  influenza  it  affects 
the  throat  and  bronchi.  I  have  felt  for  a  moment  perplexed  by  the  effects  of  a  fit 
of  crying  in  a  young  person  with  slight  febrile  disturbance,  and  the  hint  may  be 
useful  to  others. 

2.  The  sore  throat  of  scarlatina  is  characterized  by  diffuse  redness  of  the  fauces, 
vrithout  tumefaction  to  any  extent  in  the  first  instance.  That  which  sometimes 
accompanies  simple  fever  presents  less  diffuse  redness;  in  quinsy  it  is  always  as- 
sociated with  much  swelling.     In  all  of  these  the  distinctions  derived  from  febrile 


62  FEBRILE    DISEASES. 

symptoms  niT  to  be  viewed  in  connexion  with  tlic  lucal  state;  when  the  cbaracl 

•  Fever  most  nearly  approach  to  typhus  the  redness  is  most  marked,  and 
it  has  a  livid  line:  in  quinsy,  when  the  swelling  is  so  slight  as  to  can-'-  any  don  lit, 
Febrile  i\  ly  appreciable.    The  sodden  tongue  of  quinsy  has  always 

but  little  analogy  to  that  of  fever. 

In  a  well -marked  case  of  scarlatina,  there  are  generally  to  be  seen  on  the  tongue 
a  number  of  round  elevated  papilla),  which,  in  the  early  stage,  protrude  through  a 
white  Fur,  giving  it  a  dotted  appearance,  and  at  a  later  period  stand  out  From  the 
smooth  red  surface,  producing  what  is  generally  spoken  of  as  the  "sum 

lie.     This  appearance  cannot  serve  for  the  diagnosis  of  doubtful  cast  S,  except, 
perhaps,  in  a  retrospective  view. 

3.  The  pain  of  the  back  in  variolous  attacks  is  sometimes  most  remarkable.  It 
is  more  intense  than  any  similar  condition  observed  in  ordinary  fever,  in  which 
pains  in  the  limbs  generally  are  sure  to  accompany  any  local  pain  in  the  back, 
and  ion  is  observed  rather  than  excitement:  the  fever  existing  prior  to  the 

eruption  of  smallpox,  when  pain  in  the  back  is  felt,  is  usually  of  an  active  form. 
A  distinction  between  this  local  pain  and  that  of  lumbago,  in  the  general  accepta- 
tion of  the  term,  is  to  be  found  in  its  locality:  the  latter  affects  the  muscles  at  the 
side  of  the  spine,  and  is,  consequently,  much  aggravated  by  movement;  the  former 
is  more  central  in  situation  and  is  less  affected  by  change  of  posture.  The  sub- 
ject of  nephritis  will  occupy  us  at  a  later  period.  Other  causes  of  pain  in  the  back 
are  not  attended  with  symptoms  of  fever. 

Eruptive  fevers  vary  very  greatly  in  intensity  prior  to  the  ap- 
pearance of  the  cutaneous  affection;  and  it  fortunately  happens 
that,  when  the  fever  is  most  severe,  the  local  indications  just  men- 
tioned are  most  striking.  In  slight  cases,  where  the  practitioner  is 
most  likely  to  be  thrown  off  his  guard,  he  is  seldom  called  till  the 
appearance  of  the  eruption  leaves  no  room  for  hesitation  as  to  the 
cause  of  the  attack. 

The  eruptions  present  certain  distinct  forms,  which  in  their  full 
development,  become  the  basis  of  distinction  between  these  diseases, 
as  they  also  separate  them  widely  from  other  forms  of  fever.  Their 
characters,  are,  however,  occasionally  so  obscure,  that  notwithstand- 
ing all  the  aid  derived  from  antecedent  and  consequent  symptoms, 
cases  do  occur  which  are  not  free  from  ambiguity.  The  principal 
features  are  the  following: — 

1.  Measles. — The  eruption  consists  of  a  mottled  redness,  which 
appears  in  the  form  of  numerous  rose-coloured  spots,  papular,  very 
slightly  elevated,  and  grouped  mostly  in  crescentic  patches;  the 
elevation  scarcely  perceptible  to  the  touch,  and  without  any  sensa- 
tion of  hardness.  It  is  first  observed  about  the  back  and  loins,  and 
subsequently  spreads  until  it  covers  the  whole  body,  in  most  in- 
stances. 

2.  Scarlatina. — Here  we  find  a  diffused  redness,  of  more  or  less 
brilliancy,  especially  affecting  the  front  of  the  neck,  spreading  down 
on  the  chest,  and  also  appearing  at  the  bend  of  the  elbow  and  on 
the  legs,  where,  sometimes,  it  is  more  extended  and  general  than 
on  the  upper  part  of  the  body.  It  commonly  begins  with  the  neck, 
and  assumes  the  form  of  minute  points  of  redness,  which  are  in  no 
way  elevated,  and  rapidly  coalesce.  There  is  no  feeling  of  hard- 
ness or  appearance  of  boundary  line,  though  the  eruption  be  of  li- 
mited extent;  it  scarcely  ever  covers  the  whole  surface,  like  mea- 
sles. 


INTERMITTENT   FEVERS.  63 

8.  Varioloid  Eruptions  generally  first  appear  on  the  face,  pre- 
ceded by  patches  of  redness,  which  have  a  hard,  gritty  feeling  to 
the  finger;  upon  these  patches  minute  vesicles,  more  or  less  nume- 
rous, form ;  some,  or  all  of  them,  acquire  gradually  a  larger  size, 
become  filled  with  lymph,  which  passes  quickly  into  pus,  and  are 
marked  by  a  distinct  depression  in  the  centre.  In  modified  small- 
pox, after  vaccination,  the  eruption  may  be  very  scanty  indeed, — 
may,  perhaps,  only  show  itself  on  the  chest,  and  few  or  none  of  the 
vesicles  ever  enlarge  to  the  appearance  of  variolous  pustules. 

4.  Erysipelas, — a  diffused  redness,  confined  to  a  particular  lo- 
cality, with  considerable  tumefaction,  and  a  sensation  of  superficial 
hardness,  appearing  much  more  commonly  about  the  head  and  face 
than  elsewhere.  In  deep-seated  cellular  inflammation  there  may 
be  the  same  diffuse  redness  and  tumefaction,  but  the  sensation,  on 
touching  it,  is  rather  that  of  tension  than  hardness:  in  the  one, 
the  skin  itself  is  thickened  by  infiltration ;  in  the  other,  the  redness 
is  only  sympathetic,  and  the  tension  comes  from  the  infiltration  of 
the  deeper  lying  structures,  just  as  happens  in  the  redness  over  a 
joint  affected  by  acute  rheumatism. 

The  degree  of  similarity  which  they  present  has  led  to  cellular  inflammation 
being  called  phlegmonous  erysipelas;  it  has  none  of  the  characters  of  an  idiopa- 
thic fever,  which  have  led  to  our  placing  erysipelas  among  the  eruptive  fevers. 
It  is  referred,  along  with  the  remaining  acute  exanthemata,  roseola,  urticaria, 
erythema,  and  eczema,  to  the  division  of  diseases  pertaining  to  the  skin  and  cel- 
lular tissue.  This  classification  seems  objectionable,  inasmuch  as  all  of  these  are 
dependent  on  constitutional  states;  but  in  the  present  state  of  our  knowledge  we 
must  be  content  with  such  an  imperfect  arrangement.  Any  evidence  of  fever 
which  these  cases  present  only  proves  it  to  be  of  a  secondary  character,  and  they 
do  not  differ  in  having  a  constitutional  origin  from  other  skin  diseases,  which 
must  be  classed  according  to  their  prominent  symptoms,  not  according  to  their 
essential  elements. 

The  more  prominent  complications  of  these  several  disorders  have  their  uses  in 
diagnosis,  and  therefore  deserve  enumeration. 

1.  Of  measles — obstinate  bronchitis,  which  often  runs  on  to  the  deposition  of 
miliary  tubercle  throughout  the  lungs. 

2.  Of  scarlatina — suppressed  action  of  the  kidney,  albuminous  urine,  dropsy. 

3.  Of  smallpox — pleurisy,  or  pleuro-pneumonia. 

4.  Of  erysipelas,  especially  in  dissipated  habits — head  symptoms,  very  analo- 
gous to  delirium  tremens.  It  does  not  appear  that  these  are  necessarily  inflam- 
matory, but  they  may  be  produced  by  meningitis,  which  is  probably  erysipelatous 
in  its  nature.     (See  Chap.  XII.  Div.  I.,  Mental  Functions.     \  4,  Delirium.) 

Division  III. — Intermittent  Fevers. 
The  great  distinction  of  this  class  of  fevers  is  their  perfect  inter- 
mission. All  fevers  are  .liable  to  exacerbations;  and  the  remissions 
were  considered,  in  former  times,  no  less  essential  than  any  of  the 
other  symptoms,  such  as  hot  skin,  quick  pulse,  &c.  They  are  now 
regarded  rather  as  accidental,  and  dependent  on  extraneous  causes, 
than  as  belonging  to  the  necessary  effects  of  the  fever  itself,  when 
it  comes  under  any  of  the  classes  already  enumerated.  But  when 
complete  intermission  occurs,  and  when  the  patient  for  a  long  time 
feels  tolerably  well  during  the  interval,  the  type  of  fever  is  wholly 


64  febrile  diseases. 

different.  The  history  is,  therefore,  one  of  the  most  important 
guides  to  diagnosis.  If  a  patient  be  seen  just  as  the  cold  stage  is 
■  away  and  the  hot  one  commencing,  during  the  first  parox- 
i,  or  if  he  have  not  sufficient  intelligence  to  have  marked  the 
succession  of  its  stages  in  a  previous  one,  there  is  nothing  to  dis- 
tinguish it  from  simple  fever.  The  cold  stage  is  more  marked,  and 
the  heat  of  skin  is  out  of  proportion  to  the  duration  of  the  attack, 
and  to  the  appearance  of  the  tongue;  but  this  is  not  sufficient  to 
distinguish  it  from  the  incursion  of  eruptive  fever,  or  of  some  in- 
flammation, until  profuse  perspiration  follows  and  the  complete  in- 
termission arrives.  The  absence  of  the  special  indications  already 
pointed  out,  and  of  local  pain,  probably  contradict  such  an  idea; 
and  we  then  inquire  into  the  possible  causes  of  the  attack,  and 
Ily  the  exposure  to  local  malaria  rin  ague  districts. 

The  rigor  is  generally  intense,  and  the  perspiration  profuse, — 
such,  indeed,  as  are  never  met  with  except  in  deep-seated  suppura- 
tion ;  and  if  there  be  no  history  of  any  serious  derangement  of 
health,  which  would  of  necessity  accompany  previously  existing  dis- 
ease of  any  internal  organ,  there  need  be  little  doubt  of  the  nature 
of  the  case.  These  symptoms  are  soon  followed  by  complete  inter- 
mission ;  and,  finally,  the  recurrence  of  the  attack,  after  a  longer 
or  shorter  interval,  makes  up  the  entire  history  of  the  disease. 

The  completeness  of  the  intermission,  the  disappearance  of  every- 
thing like  fever  in  these  cases,  deserves  especial  observation;  be- 
cause it  forms  the  most  trust- worthy  evidence  of  the  true  nature  of 
the  disease.  Delusive  hopes,  and  perhaps  mischievous  treatment, 
are  not  unfrequently  based  upon  intermissions  which  have  an  ap- 
pearance of  regularity,  but  are  incomplete  in  other  characters.  The 
intermittents  of  the  tropics  do  not  so  invariably  follow  this  descrip- 
tion ;  but  in  this  country,  except  the  patient  be  worn  down  by  oft- 
repeated  paroxysms,  I  think  it  extremely  dangerous  in  diagnosis  to 
admit  that  any  fever  belongs  to  this  class,  simply  because  the  re- 
missions assume  some  regularity  of  type.  The  paroxysms  in  ague 
may  recur  at  the  same  time  next  day,  when  it  is  called  quotidian ; 
at  the  same  time  on  the  third  day,  tertian ;  or  at  the  same  time  on 
the  fourth  day,  quartan.  These  are  all  regular  intermittents;  and 
this  regularity  of  recurrence  is  the  rule  in  the  greater  number  of 
cases.  Occasionally  an  appearance  of  irregularity  is  produced  by 
anticipation  or  postponement  of  the  paroxysm;  the  former  in  the 
commencement,  the  latter  in  the  decline  of  the  disease;  the  rigor 
begins  half  an  hour  or  an  hour  earlier  or  later  on  each  recurrence. 
Another  cause  of  an  appearance  of  irregularity  is  the  existence  of 
what  i3  called  double-tertian :  the  paroxysms  on  the  first  and  third 
day  begin  at  the  same  hour,  but  on  the  second  day  the  rigor  comes 
on  at  some  different  period;  and  this  is  again  repeated  on  the  fourth 
day:  it  thus  stimulates  an  irregular  quotidian.  The  curative  treat- 
ment is  now  so  quick  and  efficacious  in  the  early  period,  that  op- 
portunities are  seldom  offered  in  this  country  of  studying  such  phe- 
nomena. 


INTERMITTENT   FEVERS.  65 

Sometimes  the  paroxysms  recur  at  such  irregular  intervals,  that 
the  disease  must  simply  be  called  an  irregular  intermittent.  These 
cases  are  rare;  and  when  they  supervene  on  previous  disorder,  the 
possibility  of  deep-seated  suppuration  must  be  considered  and  the 
judgment  held  in  suspense,  until  their  distinct  recurrence  on  one  or 
two  occasions,  and  the  condition  of  comparative  health  and  freedom 
from  disorder  during  the  intermission,  relieve  the  mind  from  such 
an  apprehension.  On  the  other  hand,  when  serious  derangement 
of  health  has  preceded  the  first  shivering,  irregular  paroxysms  are 
most  probably  caused  by  suppuration;  and  when  the  patient  con- 
tinues ill  during  the  intervals,  this  probability  amounts  almost  to 
certainty,  even  when  we  cannot  make  out  its  exact  seat. 


m 


CHAPTER  V. 

RHEUMATISM  AND   GOUT. 

§  1,  Acute  Rheumatism — Phenomena — Obscure  Cases — Complica- 
tions— §  2,  Sub-acute  Rheumatism — Fibrous — Synovial — Com- 
plications— §  3,  Muscular  Rheumatism — §  4,  Chronic  Rheuma- 
tism— simulated  by  Neuralyia — by  Disease  of  Joints — §  5,  Gout 
— §  6,  Rheumatic  Gout — Obscure  Nature — Duration. 

It  has  been  already  noticed  that  the  objective  phenomena  grouped 
under  position  m  posture  have  a  direct  connexion  with  the  presence 
of  rheumatic  affections.  In  general  terms,  it  may  be  said  that  the 
indication  consists  in  a  greater  or  Jess  degree  of  inability  to  move 
certain  joints,  either  in  consequence  of  the  pain  produced  by  mo- 
tion, or  of  the  stiffness  arising  from  alteration  of  texture.  Along 
■with  this  we  may  observe  swelling,  thickness,  or  distortion,  more  or 
less  marked  in  different  cases. 

The  history  is  simply  comprised  in  an  account  of  pain,  of  longer 
or  shorter  duration,  with  or  without  the  coincidence  of  general 
febrile  disturbance;  and  in  some  cases  the  swelling  of  the  joint  is 
more  spoken  of  than  its  painfulness.  The  complaint  on  the  part  of 
the  patient,  that  he  is  suffering  from  rheumatism,  is  very  liable  to 
mislead  the  medical  attendant — no  expression  is  in  more  common 
use,  and  none  more  open  to  fallacy:  the  much-abused  term,  "in- 
flammation," is  not  more  false  in  its  application.  The  student 
should  be  especially  careful  to  resolve  all  such  statements  by  fur- 
ther inquiry  into  their  true  and  simple  meaning;  and  "rheumatism," 
in  the  majority  of  cases,  is  no  more  than  an  assertion  of  the  exist- 
ence of  pain.  Another  source  of  fallacy  connected  with  the  pa- 
tient's description  is,  that  he  speaks  of  having  "  lost  the  use  of  his 
limb,"  when  its  immobility  is  clue  to  pain  or  to  stiffness  of  the 
joint,  as  well  as  when  it  is  caused  by  paralysis.  Handling  the  limb 
is  the  most  effectual  mode  of  discriminating  these  three  conditions. 

The  history  of  the  case  may  be  also  available  for  distinguishing 
between  the  various  affections  embraced  under  the  head  of  rheuma- 
tism, as  it  points  out  the  severity  of  the  sufferings  and  the  duration 
of  the  attack,  its  limitation  to  one  limb,  or  its  transference  to 
others.  We  should  never  omit  to  inquire  whether  there  have  been 
any  previous  attack  of  a  similar  character ;  both  because  of  the 
bearing  this  has  on  disease  of  the  heart,  and  also  because  the  cha- 
racters of  the  affection  are  apt  to  be  less  pronounced  in  proportion 
to  the  frequency  of  their  repetition. 

§  1.  Acute  Rheumatism. — The  general  symptoms  indicate  the 


ACUTE   RHEUMATISM.  67 

presence  of  a  febrile  or  inflammatory  disorder:  the  sensations  of 
the  patient  refer  especially  to  the  existence  of  pain.  Our  next  step 
is  to  ascertain  its  locality, — whether  felt  in  the  limbs,  and  spoken 
of  as  "pains  in  the  bones,"  so  common  in  fever;  or  in  some  defined 
situation,  as  the  effect  of  simple  inflammation ;  or  whether  confined 
to  the  joints  themselves.  If  the  patient,  in  his  description,  follow 
it  from  one  joint  to  another, — the  ankles,  the  knees,  the  hips,  the 
wrists,  elbows,  and  shoulders, — we  may  be  sure  that  the  disease  is 
acute  rheumatism. 

In  this  form,  the  pain  is  severe, — not  coming  in  twinges,  nor  ac- 
companied by  startings,  (muscular  spasm,) — but  continuous,  aggra- 
vated by  motion,  and  intolerant  of  pressure ;  sometimes  so  intense, 
that  the  weight  of  the  bed-clothes  cannot  be  borne;  every  posture 
alike  uneasy,  the  patient  would  fain  alter  it,  but  that  the  dread  of 
increased  suffering  in  the  attempt  commonly  restrains  him.  Flying 
from  one  limb  to  another,  or  affecting  all  nearly  alike,  the  wrists 
and  ankles  are  more  especially  prone  to  suffer  in  acute  rheumatism  ; 
and  these  joints  are  commonly  tumid  and  extremely  tender,  and 
marked  by  a  superficial  erythematous  blush.  Along  with  these 
evidences  of  general  disturbance  and  local  suffering,  the  profuse 
perspiration,  of  a  peculiar  odour,  distinguishes  it,  in  a  most  unmis- 
takable manner,  in  its  severer  forms.  But  the  student  must  remem- 
ber that  sour-smelling  perspiration,  though  very  constant,  in  this 
disease,  will  certainly  mislead  him  if  the  more  essential  indications 
be  overlooked.  This  acid  odour  has  sometimes  a  certain  rancidity 
combined  with  it,  which,  when  present,  is  perhaps  more  diagnostic: 
in  all  cases,  however,  solitary  signs  are  not  trustworthy. 

Fever  may  run  high,  the  tongue  be  foul,  and  the  pulse  quick,  and  the  local  in- 
dications of  pain  and' swelling  be  very  slight  at  the  time  of  observation.  This  may 
be  caused  by  various  circumstances. 

a.  The  case  maybe  one  of  continued  fever,  with  slight  rheumatism  superadded. 
The  pain  will  at  no  time  have  been  intense,  the  limbs  never  having  been  rendered 
motionless  from  suffering;  the  febrile  symptoms  present  somewhat  of  an  asthenic 
type;  the  pulse  is  weak  as  well  as  quick,  and  perspiration  is  less  common.  In 
acute  rheumatism  it  may  be  remarked,  that  the  general  symptoms  of  a  febrile 
state  differ  in  many  important  respects  from  those  of  continued  fever,  as  they  in- 
dicate a  certain  amount  of  inflammatory  action:  on  the  other  hand,  they  form  a 
striking  contrast  to  those  of  most  of  the  sthenic  inflammations  in  the  presence  of 
excessive  perspiration. 

6.  In  children,  when  evidence  of  the  disease  being  acute  is  not  wanting,  the 
local  affection  may  not  be  very  pronounced;  the  joints,  perhaps  never  tumid  or 
red,  the  patient  tossing  about  in  bed  in  such  a  way  as  to  lead  us  to  doubt  whether 
there  be  any  real  inflammation  of  either  ligaments  or  synovial  membranes.  1  et 
serious  mischief  may  result  by  inflammation  of  the  lining  membrane  of  the  heart 
or  the  pericardium.  In  forming  a  diagnosis  in  such  cases,  it  is  to  be  remembered 
that  children  are  not  conscious  that  perfect  stillness  will  best  remedy  their  suffer- 
ings; but  it  is  also  true  that  internal  inflammation  may  prevent  any  external  de- 
velopment of  the  disease.  The  continued  or  remittent  fever  of  childhood  is  never 
accompanied  by  local  pain,  and,  therefore,  when  pain  in  the  limbs  is  observed  as 
a  concomitant  of  a  febrile  state,  rheumatic  affection  is  at  least  to  be  suspected^ 

c.  Not  merely  in  childhood,  but  also  among  adults,  the  occurrence  of  severe  in- 
ternal inflammation  will  often  abolish  the  signs  of  local  affection  of  the  joints;  and 


03  RUE  CM  AT  ISM    AND    GOUT. 

hero  we  shall  derive  most  aid  from  a  careful  inquiry  into  the  patient's  previous 
In  comparatively  rare  instances,  the  external  Bigna  of  the  disease  only  fol- 
low after  the  subsidence  of  some  interna]  inflammation.    These  occurrences  are 
must  particularly  associated  with  pericarditis:  Lut  endocarditis  and  pleurisy  may 

aL-n  become  causes  of  obscurity  in  febrile  conditions  connected  with  rheumatism. 

Ther  •  is  really  little  practical  difficulty  in  recognising  a  case  of  acute  rhenma- 
;  we  have  only  to  distinguish  it  from  gout,  and  from  the  inflammation  of  the 

joints  attending  on  secondary  deposit :  and  their  diagnosis  must  be  more  fully  con- 
sidered in  subsequent  sections.  A  first  attack  is  generally  the  best  defined:  the 
|  at  is  probably  under  thirty;  the  redness  of  the  skin  confined  to  the  part  im- 
liately  over  the  joint,  the  pain  and  tenderness  out  of  all  proportion  to  the  as- 
of  inflammation,  and  various  joints  suffering  simultaneously.  In  any  other 
than  a  first  attack,  the  history  of  the  former  seizure  may  prove  that  to  have  been 
gout,  and  will  naturally  lead  us  to  suspect  that  this,  though  less  defined,  is  pro- 
f  gout  too.  The  previous  occurrence  of  either  renders  it  probable  that  the 
present  disease  is  not  connected  with  purulent  contamination  of  the  blood.  The 
history,  again,  of  its  commencement  and  progress,  in  gout  or  rheumatism,  differs 
from  that  usually  obtained  in  a  case  of  pyaemia:  in  the  latter,  there  is  some  exist- 
ing suppuration  or  inflammation  of  veins  or  absorbents,  which  was  perhaps  re- 
used long  before  inflammation  attacked  the  joints;  and  we  are  thus  prepared 
to  look  for  its  occurrence:  sometimes,  however,  the  process  is  a  very  rapid  one, 
and  the  attack  exceedingly  like  acute  rheumatism  to  the  inexperienced.  One  or 
two  points  aid  very  much  in  the  discrimination,  as  they  are  connected  with  the 
essential  nature  of  the  disease.  The  inflammation  round  the  joint  is  more  ery- 
sipelatous in  appearance,  and  is  combined  with  oedema,  and  the  pain  is  less  severe; 
other  parts,  at  a  distance  from  any  joint,  are  similarly  affected;  or  there  may  be 
inflammation  about  the  eyedids,  soreness  of  throat,  &c. :  the  fever  is  adynamic, 
and  the  patient  depressed ;  the  inflammation  constantly  passes  on  to  suppuration 
— which  never  happens  in  acute  rheumatism. 

1 1  lirium  is  occasionally  associated  with  acute  rheumatism,  and  we  may  satisfy 
ourselves,  in  the  majority  of  cases,  that  it  is  not  due  to  inflammation  of  the  brain, 
but  merely  an  evidence  of  deterioration  of  blood,  or  of  laboured  circulation,  con- 
sequent upon  inflammation  of  the  heart.  It  can  only  cause  anxiety  when  the  dis- 
ease has  suddenly  receded  from  the  joints,  and  has  not  affected  the  heart ;  because, 
as  will  be  shown  when  speaking  of  delirium,  we  may  then  possibly  have  metastasis 
to  the  brain.  In  the  chest  are  to  be  found  the  most  constant  complications  of 
acute  rheumatism.  By  far  the  larger  number  of  cases  of  pericarditis  which  have 
been  recognised  during  life  occur  in  the  progress  of  this  disease,  and  a  consider- 
able proportion  of  the  permanent  valvular  lesions  may  be  observed  to  take  their 
rise  in  rheumatic  endocarditis,  or  may  be  traced  back,  with  very  great  probability, 
to  it.  The  condition  of  the  heart  must  therefore  be  watched  from  day  to  day  :  we 
must  also  be  prepared  for  the  incursion  of  pleurisy;  and  bronchitis  sometimes  be- 
comes a  serious  and  troublesome  complication. 

§  2.  Sub-acute  Rheumatism. — When  the  febrile  state  is  less 
marked,  when  the  inflammation  of  the  joints  is  less  severe,  and  the 
number  affected  smaller,  we  have  a  form  of  rheumatism  which  has 
been  called  sub-acute.  It  may  differ  in  no  essential  particular  from 
acute  rheumatism,  except  in  intensity;  in  no  one  symptom,  proba- 
bly, so  much  as  in  the  amount  of  tenderness;  there  is  generally 
considerable  swelling,  and,  in  some  instances,  a  good  deal  of  red- 
ness ;  but  the  exquisite  sensibility  of  acute  rheumatism  is  wanting. 
Some  of  the  cases  belonging  to  this  class  are  of  short  duration,  as 
if  they  were  abortive  attacks  of  the  acute  form.  Some  continue 
for  a  long  period,  and  take  on  the  characters  known  as  rheumatic 
gout.  Others,  on  the  contrary,  present  this  peculiarity,  that  the 
disease  is  in  great  measure,  or  entirely,  limited  either  to  one  joint 


SUB-ACUTE   RHEUMATISM.  69 

or  to  a  single  extremity.  The  symptoms  connected  with  the  local 
disturbance  may  be  tolerably  severe,  but  it  remains  fixed  there,  and 
the  disease  is  commonly  very  obstinate  and  much  prolonged  in  its 
duration.  Such  cases  are  liable  to  be  taken  for  simple  inflammation 
of  the  joint,  or  synovitis.  The  best  guide  in  determining  their  na- 
ture is  to  be  found  in  the  history  of  the  case.  Rheumatism  almost 
always  appears  in  several  joints  before  it  becomes  located  in  one ; 
and,  on  inquiry,  perhaps  we  learn  that  the  patient  has  had  previous 
attacks  of  rheumatism  or  gout.  The  history  of  simple  inflamma- 
tion generally  points  to  some  accident  or  injury,  acting  as  the  ex- 
citing cause,  or  it  tells  of  syphilis,  with  nodes  or  lichenous  eruption. 
The  diagnosis  is  necessarily  imperfect,  inasmuch  as  both  diseases 
have  an  inflammatory  character;  and  it  is  remarkable  that,  in  per- 
sons of  gouty  or  rheumatic  habit,  the  inflammation,  set  up  by  acci- 
dent or  injury,  often  assumes  a  specific  type,  just  as  we  find  inflam- 
matory action  modified,  in  other  instances,  by  some  peculiar  diathesis 
of  the  patient,  e.  g.,  the  scrofulous. 

The  varieties  of  sub-acute  rheumatism  derive  their  distinctive  characters,  in 
a  great  measure,  from  the  circumstance  that  in  some  cases  the  fibrous  structures 
around  the  joint,  in  others  the  synovial  membrane,  is  the  seat  of  the  local  inflam- 
matory action.  In  acute  rheumatism  the  two  are  more  intimately  blended;  in  the 
sub-acute  form  it  is  not  difficult  to  distinguish  the  thickening  of  the  ligamentous 
structures,  which  are  firm  and  resisting,  from  the  puffy  elasticity  and~feeling  of 
fluctuation  communicated  by  the  presence  of  fluid  in  the  cavity  of  the  joint.  The 
first  is  more  frequently  met  with  in  the  smaller  joints  of  the  wrists  and  fingers: 
the  other,  by  far  the  most  frequently,  in  the  knee,  where  the  accumulation  of  fluid 
is  sometimes  very  remarkable. 

Among  the  complications  of  sub-acute  rheumatism  gonorrhoea  is  one  of  the 
most  important,  especially  in  the  male  sex.  It  is  a  very  frequent  association  of 
that  form  in  which  the  swelling  and  redness  seem  to  indicate  very  acute  action, 
while  the  absence  of  pain  and  of  fever,  and  the  limited  nature  of  the  affection, 
really  lead  to  an  opposite  conclusion. 

A  very  serious  affection  of  the  brain  is  occasionally  seen  as  a  complication  of 
synovial  rheumatism,  when,  during  its  progress,  the  sudden  absorption  of  the  fluid 
is  followed  by  delirium  and  coma. 

In  sub-acute  rheumatism,  affections  of  the  lungs  and  heart  are  much  less  com- 
mon than  in  the  acute  form. 

Synovitis  is  the  disease  which  most  nearly  resembles  sub-acute  rheumatism ; 
and  from  this,  as  we  have  already  seen,  it  can  only  be  distinguished  by  analyzing 
the  causes  of  the  affection;  the  local  action  is  the  same  in  each.  Other  diseases 
of  the  joints  are  more  liable  to  be  confounded  with  chronic  rheumatism,  under 
which  head  their  distinguishing  characters  will  be  more  fully  considered. 

Here  we  have  only  to  notice,  that  in  certain  cases  in  which  the  knee-joint  is  af- 
fected with  absolute  thickening  and  degeneration  of  the  synovial  membrane,  the 
external  aspect  closely  resembles  that  which  is  produced  by  the  presence  of  fluid  in 
synovial  rheumatism.  The  history  of  cases  of  joint-disease  is  generally  obscure, 
and  extends  over  a  long  period;  their  progress  is  insidious,  and  they  are  especially 
distinguished  from  rheumatic  affections  by  the  absence  of  pain  in  their  commence- 
ment. The  degeneration  of  the  synovial  membrane  last  alluded  to  is,  indeed,  al- 
most painless  throughout:  its  shape  sufficiently  characterizes  it  as  an  affection  of 
the  synovial  membrane,  while  the  feeling  of  elasticity  aud  absence  of  fluctuation 
show  that  there  is  no  accumulation  of  fluid. 

§  3.  Muscular  Rheumatism. — Pain  and  stiffness  of  rheumatic 
origin  may  also  attack  the  muscular  structures.     It  occurs  with  or 


70  RHEUMATISM    AND   GOUT. 

without  attendant  fever;  but  it  cannot  be  supposed  that,  in  so  slight 
a  malady,  the  fever  is  symptomatic,  the  two  are  rather  coincident 
affections;  and  -we  must  be  careful  to  make  out  distinctly  that  such 
is  the  fact;  for  when  the  pyrexia  arises  from  a  local  affection,  ten- 
sion and  hardness  will  be  observed  as  well  as  tenderness,  indicating 
the  presence  of  the  products  of  inflammation,  in  the  effusion  of 
lymph  or  serum,  and  proving  that  the  disease  is  not  rheumatism. 
In  the  absence  of  fever,  the  disorder  cannot  be  called  "chronic," 
because  of  its  short  duration  and  transient  nature ;  but  we  may  call 
it  "slight"  rheumatism.  In  a  diagnostic  point  of  view,  we  recog- 
nise the  existence  of  pain,  more  or  less  constant,  aggravated,  or 
only  called  into  existence  by  muscular  movement;  passive  motion 
not  being  attended  with  pain,  as  it  is  in  rheumatism  of  the  joints, 
except  when,  by  antagonism,  some  muscle  is  called  into  action. 

This  is  one  of  the  causes  of  lumbago,  the  most  severe  form  of 
muscular  rheumatism.  Its  diagnosis  must  not  rest  upon  this,  its 
prominent  symptom;  but  careful  inquiry  must  be  made  into  the 
condition  of  the  spine  and  the  kidneys,  which  may  each  be  the 
cause  of  pain  in  the  loins. 

§  4.  Chronic  Rheumatism. — Pain  and  stiffness  of  the  ligamentous 
structures,  often  of  long  duration,  with  or  without  thickening  of 
parts,  and  increased  by  motion  of  the  joints  or  handling  of  the 
limb,  when  unaccompanied  by  marked  tenderness  or  febrile  action, 
is  to  be  classed  under  the  denomination  of  chronic  rheumatism. 

It  is  not  possible  to  specif}7,  with  any  degree  of  accuracy,  the 
exact  element  of  this  form  of  disease;  but  it  is  very  important  that 
the  practitioner  should  be  able  to  distinguish  painful  affections  de- 
pendent on  other  causes  from  those  which,  in  the  absence  of  posi- 
tive indications  to  the  contrary,  must  be  regarded  as  rheumatic.  In 
the  subsequent  recurrence  of  the  disease,  patients  themselves  are 
often  able  to  discriminate  very  exactly  between  the  pain  of  rheu- 
matism and  that  of  other  disorders,  but  too  much  reliance  must  not 
be  placed  on  such  statements. 

The  early  history  generally  points  to  pain  as  the  first  or  the  only 
indication,  altered  form  or  structure  being  a  later  or  secondary 
effect.  Occasionally  it  occurs  as  the  sequel  of  an  acute  attack 
which  has  not  been  followed  by  complete  convalescence,  but  more 
frequently  it  has  no  such  origin;  nor  does  it  appear  that  the  subjects 
of  chronic  rheumatism  have  been,  in  any  large  proportion,  affected 
with  acute  rheumatism  at  former  periods.  It  is  much  more  common 
in  advanced  than  in  early  life.  Simultaneous  affection  of  several 
joints,  indicating  the  constitutional  nature  of  the  disease,  is  not  so 
frequently  met  with  in  this  as  in  other  forms  of  rheumatism;  nor 
are  there  any  general  symptoms  constantly  associated  with  it.  The 
inquiry  into  the  condition  of  other  organs  often  brings  to  light  dis- 
ordered functions  or  impaired  nutrition,  which  have  an  indirect  but 
important  relation  to  the  disease,  and  are  even  more  essential  to  its 
correct  treatment  than  perfect  knowledge  of  the  local  condition. 


CHRONIC    RHEUMATISM.  1 1 

When  affecting  the  smaller  joints,  alterations  of  form  are  moft 
frequently  seen  as  its  result  than  when  the  larger  ones  are  espe- 
cially attacked,  and,  at  all  events,  from  their  situation,  the  swelling 
or  distortion  is  more  readily  perceived ;  but  its  site  is  rather  in  the 
latter  than  in  the  former.  The  shoulders,  the  hips,  and  the  liga- 
mentous structures  of  the  back  are  its  common  situations,  and,  next 
in  order,  the  knees,  ankles,  and  elbows ;  in  the  hands  and  feet  the 
disease  is  more  likely  to  be  of  a  gouty  nature,  or  at  least  to  corre- 
spond to  what  is  called  rheumatic  gout. 

With  reference  to  diagnosis,  we  have  to  discriminate  diseases  accompanied  by 
pain  in  situations  where  chronic  rheumatism  is  usually  met  with,  and  diseases  of 
the  joints  which  are  not  rheumatic.  The  painful  affections  are  chiefly  neuralgic 
or  sympathetic  in  the  shoulder  and  upper  part  of  the  back,  those  connected  with 
disorder  of  the  liver  and  dyspepsia;  across  the  loins,  those  produced  by  affections 
of  the  kidney;  at  the  lower  part  of  the  back,  in  females,  those  associated  with  va- 
ginal discharges  and  uterine  disease;  while  in  the  hip  and  thigh  it  is  often  very 
difficult  to  make  out  whether  the  pain  is  of  the  ordinary  rheumatic  character,  or 
is  dependent  on  sciatica,  which  itself  may  be  only  a  manifestation  of  rheumatism. 
In  all  of  these  cases  we  derive  great  aid  from  the  consideration,  that  in  rheumatic 
affections  the  pain  is  increased  by  movement:  each,  however,  presents  peculiar 
characters  which  serve  to  confirm  our  diagnosis.  In  disorders  of  digestion,  the 
prominence  of  the  symptoms  bearing  more  directly  upon  the  function  itself;  in 
nephralgia  and  nephritis  the  pain  described  as  shooting  down  to  the  groin,  thigh, 
or  testicle;  in  uterine  affections,  the  seat  of  pain  corresponding  to  the  sacrum, 
where  movement  cannot  be  its  exciting  cause;  and  in  sciatica,  the  pain  following 
the  course  of  the  nerve  down  the  back  and  inside  of  the  thigh,  serves  to  discrimi- 
nate it  from  one  spoken  of  as  extending  from  the  hip  to  the  ankle,  simply  because 
all  the  joints  of  the  limb  happen  to  be  simultaneously  affected. 

The  diseases  of  the  joints  do  not  properly  fall  under  our  notice  in  medical  diag- 
nosis, but  yet  it  is  very  necessary  we  should  be  able  to,  satisfy  our  own  minds 
whether,  in  any  given  case,  there  be  not  some  more  definite  disease  going  on  than 
that  which,  for  want  of  more  accurate  knowledge,  we  call  rheumatic.  We  have 
already  noticed  the  degeneration  of  the  synovial  membrane,  and  we  have  still  to 
mention  ulceration  of  cartilages,  scrofulous  disease  of  bones,  and  caries  of  the 
spine.  In  regard  to  all  we  observe,  that  their  course  is  very  protracted,  their 
commencement  insidious,  and  that  they  are  chiefly  characterized  by  absence  of 
pain  in  the  early  stage;  pain,  when  it  does  come  on,  is  shooting,  transitory,  and 
frequently  attended  by  starting  of  the  limbs;  it  is  only  in  the  advanced  stages 
that  it  presents  any  permanence  of  character.  We  may  further  observe,  not  only 
that  there  is  absence  of  pain  in  the  quiescent  state,  but  that  cautious  movement 
does  not  bring  it  on,  while  the  slightest  jar,  causing  concussion  of  one  bone  against 
another,  is  sure  to  cause  pain,  and  that  sometimes  of  very  severe  kind.  The  pa- 
tient who  cannot  bear  his  own  weight  on  the  ground  while  perfectly  motionless, 
is  capable  of  much  movement  in  bed  without  suffering,  when  the  pressure  is  re- 
moved from  the  affected  joint.  A  very  frequent  source  of  obscurity  in  the  early 
history  of  these  cases  is  the  circumstance  that  pain  is  not  referred  to  the  joint  it- 
self, but  to  a  more  distant  one,  in  which  it  is  only  sympathetic;  this  point,  when 
ascertained,  serves  as  an  additional  ground  for  diagnosis.  The  age  and  aspect  of 
the  patient  are  suggestive  with  reference  to  the  nature  of  the  affection ;  thus  we 
look  for  disease  of  bone  in  the  young  and  delicate,  ulceration  of  cartilages  in  the 
early  part  of  adult  life,  and  chronic  rheumatism  after  its  middle  period,  in  persons 
who  are  fat  and  flabby  or  cachectic  and  anaemic.  In  caries  of  the  spine,  the  early 
progress  of  the  case  is  scarcely  marked  by  any  feature  which  can  distinguish  it, 
till  the  prominence  of  one  spinous  process  at  the  seat  of  pain  indicates  the  irre- 
parable mischief  which  has  already  taken  place.  In  connexion  with  this  we  must 
not  forget  that  lumbar  and  psoas  abscess,  or  deep-seated  pelvic  inflammation  and 


72  11 II  HUM  ATI  SM    AND    GOUT. 

•    raration,  when  advancing  slowly,  are  apt  to  simulate  rheumatic  affections  of 
the  loins  and  bipa. 

In  chronic  rheumatism  we  chiefly  meet  with  two  important  complications,  which 
seem  each  to  have  more  or  less  to  do  with  its  development  when  present — consti- 
tutional syphilis  and  granular  degeneration  of  the  kidney.     It  is  also  intimately 
<1  with  mal-uutrition,  whether  tending  to  accumulation  of  fat  or  to  general 
cachexia. 

§  5.  Gout. — The  researches  of  recent  times  have  gradually  led 
to  the  discovery  of  an  important  element  in  gout — the  presence  of 
an  excess  of  uric  acid  in  the  blood.  This  knowledge  holds  out  a 
prospect  of  our  arriving  ultimately  at  more  accurate  diagnosis;  at 
present  it  is  only  in  the  hands  of  a  few  that  such  a  chemical  test 
can  be  relied  on.  But  we  may  derive,  from  the  mode  of  its  attack, 
pretty  certain  indications  of  the  nature  of  this  disease. 

In  regard  to  history,  an  attack  of  gout  is  usually  ushered  in  by 
dyspeptic  symptoms  and  feeling  of  discomfort,  for  some  period  be- 
fore it  becomes  localized  in  the  joints ;  and  this,  it  may  be  remarked, 
is  not  generally  the  case  with  rheumatism.  Further,  in  the  first 
seizure,  the  pain  and  redness  are  almost  invariably  confined  to  the 
smaller  joints,  especially  those  of  the  foot.  In  any  subsequent  ill- 
ness, where  the  evidence  is  at  all  indistinct,  the  manner  of  its  first 
incursion  must  be  carefully  inquired  into,  because  the  statement  of 
the  patient  that  he  has  previously  suffered  from  either  gout  or  rheu- 
matism is  generally  not  trustworthy. 

When  the  joint  is  already  attacked  and  this  is  very  commonly 
the  great  toe  in  the  early  seizures,  the  disease  is  marked  by  intense 
pain,  redness,  and  inflammatory  swelling,  just  as  in  acute  rheuma- 
tism ;  but  there  is  no  great  amount  of  inflammatory  fever.  If  it 
tend  to  pass  from  one  foot  to  the  other,  it  does  not  fly  from  joint  to 
joint  all  over  the  body;  but  as  it  appears  in  one  extremity,  it  usu- 
ally recedes  from  the  other.  The  pain  is  commonly  aggravated  at 
night.  There  is  none  in  the  shoulders,  the  hips,  or  the  knees;  and 
while,  in  these  respects  it  resembles  the  abortive  attack  of  rheuma- 
tic fever  which  we  have  described  as  sub-acute  rheumatism,  confined 
to  one  joint  or  to  one  extremity,  the  inflammatory  action  of  that  is 
very  much  greater  in  intensity  and  painfullness.  In  a  few  words, 
the  condition  of  the  joint  resembles  that  seen  in  acute  rheumatism, 
while  the  state  of  the  patient  is  more  analogous  to  the  sub-acute 
form  of  the  disease,  in  the  absence  of  fever,  perspiration,  &c. 

It  is  very  rare  that  a  first  attack  should  localize  itself  anywhere 
but  in  the  foot;  and  this  fact,  therefore,  becomes  a  great  help  in 
determining  the  nature  of  subsequent  illnesses,  when  the  hands,  or 
even  the  knees,  the  shoulders,  and  the  hips  may  be  the  seat  of  the 
gouty  paroxysm.  Repeated  attacks  of  gout  very  frequently  leave 
chalky  deposits  in  the  textures  around  the  joints,  and  these  serve 
as  landmarks  to  distinguish  cases  which  would  otherwise  be  very 
perplexing.  The  more  frequently  the  patient  has  suffered,  the  less 
defined  does  the  character  of  each  seizure  become,  until  the  descrip- 
tion of  the  case,  but  for  these  two  circumstances,  is  scarcely  to  be 


GOUT.  73 

recognised  as  at  all  different  from  sub-acute  rheumatism.  All  the 
conditions  are  then  greatly  modified;  the  pain  and  swelling  are  less 
severe;  the  number  and  variety  of  joints  implicated  much  increased. 

Gout  can  scarcely  be  confounded  with  the  local  suppurations  in  and  around  the 
joints  seen  in  pyaemia,  the  general  disturbance  of  suppurative  fever  being  so  dif- 
ferent from  the  dyspepsia  preceding  gout.  It  may  be  useful  to  add  that,  -while 
the  redness  and  swelling  are  in  both  cases  well-marked  and  of  limited  extent,  the 
one  is  a  much  more  painful  affection  than  the  other :  it  is  quite  remarkable  how 
very  little  suffering  is  occasioned  by  these  secondary  suppurations. 

The  history  of  any  previous  seizure  may  be  made  available  for  diagnosis  by  a 
comparison  of  the  age  of  the  patient  with  the  date  of  the  first  appearance  of  the 
disease.  Gout  seldom  shows  itself  before  the  middle  period  of  life,  while  a  first 
attack  of  acute  rheumatism  is  rarely  met  with  after  that  age.  The  different  dura- 
tion of  the  attack  in  each  case  should  also  be  borne  in  mind. 

Along  with  these  we  must  take  into  consideration  the  habits  and  aspect  of  the 
patient;  for,  while  it  is  true  that  no  degree  of  abstemiousness  will  serve  to  ward 
off  the  occurrence  of  gout  when  the  predisposition  is  strong,  it  is  unquestionably 
among  the  over-fed  and  the  plethoric  that  it  is  most  constantly  found. 

No  positive  rules  of  diagnosis  can  be  laid  down  for  determining  the  nature  of 
what  has  been  called  erratic  or  unfixed  gout:  but  we  shall  very  generally  be  right 
iu  concluding  that  anomalous  eases  of  disorder  in  gouty  habits  are  more  or  less 
due  to,  or  modified  by,  the  excess  of  uric  acid.  Gout  is  especially  associated  with 
disease  of  the  kidney:  and  so  frequently  has  this  been  observed,  that  some  patho- 
logists have  spoken  of  the  gouty  kidney,  a  phraseology  which  is  highly  objection- 
*able.  "We  may  be  also  prepared  to  find  other  ill  effects  of  intemperance  in  those 
who  have  brought  on  themselves  this  painful  infliction,  but  none  of  them  have  any 
definite  relation  to  it. 

§  6.  Rheumatic  Gout. — We  cannot  refuse  a  separate  place  in  our 
classification  to  a  disease  which,  though  its  place  in  pathology  be 
as  yet  undetermined,  is  very  well  marked  in  particular  cases.  The 
peculiar  twisting  and  distortion  of  the  joints  in  persons  who  have 
suffered  for  any  length  of  time  from  its  effects,  is  such  as  cannot 
pass  unobserved  by  any  one  who  is  familiar  with  the  aspect  of  dis- 
ease. 

In  its  early  history  it  partakes  most  of  the  character  of  sub-acute 
rheumatism.  It  differs  from  an  acute  attack  chiefly  in  the  absence 
of  fever,  and  in  the  circumstance  that  comparatively  few  of  the 
joints  are  under  its  influence  at  the  period  of  its  commencement; 
there  is  a  good  deal  of  swelling,  and  perhaps  of  redness,  of  one  or 
two  joints,  but  these  are  not  marked  by  the  extreme  tenderness  and 
pain  so  distinctive  of  rheumatic  fever  or  of  gout ;  while  the  local  in- 
flammation is  more  decided  than  in  the  sub-acute  form  of  the  dis- 
ease, if  we  except  a  few  cases  which  we  have  characterized  as  abor- 
tive attacks  of  acute  rheumatism.  If  due  consideration  be  given  to 
these  circumstances,  the  practitioner  will  be  prepared  for  the  incur- 
sion of  a  most  inveterate  and  most  hopeless  malady.  And,  let  it 
be  remembered,  that  diagnosis  has  in  this  case  very  much  to  do  with 
prognosis :  where  "we  recognise  rheumatic  fever,  we  know  that,  ex- 
cept the  heart  become  implicated,  the  patient  will  be  in  a  few  weeks 
at  most,  as  well  as  ever,  and  that  he  is  not  very  much  more  liable 
to  a  second  attack  than  his  neighbours:  when  gout  is  clearly  estab- 


74  UIIEUMATISM   AND   GOUT. 

lished,  avc  arc  sure  that  the  patient  will  be,  for  a  time,  in  better 
health  than  usual  after  the  present  pain  and  distress  have  subsided; 
but  that  all  the  care  possible  will  scarcely  serve  to  ward  oft'  a  se- 
cond attack :  when  we  have  only  sub-acute  rheumatism  to  deal  with, 
we  look  for  either  a  trivial  and  passing  affection,  or  for  a  lingering 
illness,  as  we  find  less  or  more  of  local  action;  but,  with  rheumatic 
gout,  we  ought  to  know  that  our  patient  is  exposed  to  protracted 
suffering,  and  is  liable  to  remain  a  cripple  for  life.  "When  this  is 
not  foreseen,  much  discredit  may  unnecessarily  be  brought  on  the 
profession — much  undue  praise  be  given  to  the  quack,  into  whose 
hands  such  cases  are  very  apt  to  fall ;  he  will  not  scruple  to  throw 
on  the  regular  attendant  the  blame  of  all  the  mischief  which  has 
happened,  and  claim  for  himself  the  credit  of  any  improvement 
which,  under  favourable  circumstances,  nature  herself  may  slowly 
produce. 

As  the  disease  proceeds,  its  peculiar  characters  begin  to  develop 
themselves:  the  swelling  subsides  in  some  measure;  the  redness,  if 
any,  is  gone  from  the  joints  first  attacked,  but  they  remain  stiff, 
tender,  and  useless;  while  others,  in  succession,  become  the  seat  of 
inflammatory  action;  until,  at  length,  the  unfortunate  patient  is  re- 
duced to  a  condition  of  utter  helplessness.  "When  convalescence  has , 
slowly  been  established,  as  it  may  be,  after  either  months  or  years 
of  suffering,  considerable  distortion  and  permanent  stiffness  is  the 
invariable  result. 

Observation  seems  to  prove  that  this  form  of  disease  is  especially 
prone  to  attack  females  at  the  two  great  periods  of  the  commence- 
ment and  cessation  of  the  menstrual  functions.  It  is  also  frequently 
associated  with  constitutional  disorder,  in  the  form  of  scrofula,  tu- 
bercle, or  disease  of  the  kidney;  but  we  know  not  in  what  relation 
they  stand  to  each  other. 


75 


CHAPTER  VI. 


DISEASES    OF    ADVENTITIOUS    ORIGIN. 

Characteristics  of  the  Class.  Div.  I. — Poisoning — §  1,  Common 
Poisons — Irritant — Narcotic — Cf-aseous — §  2,  Animal  Virus — 
Syphilis — Hydrophobia — Glanders — §  3,  Colica  Pictonum. 

Div.  II. — Entozoa — §  1,  Uchino-coccus — §  2,  Intestinal  Worms. 

In  all  the  diseases  which  have  hitherto  come  before  us  we  have 
found  that  the  element  of  disease  is  more  or  less  beyond  our  reach. 
Each  group  of  symptoms,  when  complete,  stands  quite  apart  from 
any  other  group ;  and  we  are  sure  that  it  has  its  own  separate  and 
distinct  cause  in  some  contamination  of  the  blood.  This  may  be 
solely  produced  by  external  agents,  as  in  the  intermittents;  or, 
■while  partly  derived  from  without,  the  poison  may  be  in  part  gene- 
rated, or  multiplied,  in  the  body  itself — as  seen  in  typhus  fever,  the 
exanthemata,  &c. ;  or  it  may  be  entirely  generated  in  the  body,  as 
in  rheumatism  and  gout.  To  the  congeries  of  symptoms  thus  ob- 
served, along  with  the  supposed  cause  of  their  existence,  the  name 
of  the  disease  is  applied. 

We  now  come  to  a  class  of  diseases  in  which,  in  addition  to  our 
knowledge  of  the  symptoms,  we  can,  in  certain  cases,  take  actual 
cognizance  of  a  foreign  substance  which  originates  them.  It  in- 
cludes those  commonly  known  as  the  effect  of  poisons — whether  ani- 
mal, vegetable,  or  mineral;  and  those  parasites  which  infest  the  in- 
ternal organs,  the  entozoa. 

Division  I. — Poisoning. 

The  class  is  an  inconvenient  one,  so  far  as  the  principles  of  diagnosis  are  con- 
cerned, because  the  symptoms  may  be  general  or  they  may  be  quite  local ;  they 
may  be  rapid  in  their  access,  or  very  slow  in  their  progress  ;  they  may  be  almost 
entirely  independent  of  the  peculiar  nature  of  the  poison,  or  they  may  be  specific, 
just  as  they  consist  of  vital  actions  set  up  by  the  presence  of  a  foreign  body  or  of 
special  perversions  of  function  or  nutrition  which  are  induced  by  it.  Their  only 
point  in  common  is  the  history,  when  such  can  be  obtained,  of  a  poison  actually 
received  into  the  body.  When  this  is  known,  and  the  symptoms  follow  in  the 
succession  in  which  experience  has  taught  that  they  ought  to  do,  the  diagnosis  is 
complete. 

The  class  is  also  imperfect  in  a  scientific  point  of  view,  because  one  at  least 
(syphilis)  has  a  tendency  to  increase  by  a  process  of  development  after  its  admis- 
sion. It  thus  might,  perhaps,  be  more  justly  ranged  along  with  the  zymotic  poi- 
sons, were  it  not  that  it  is  clearly  separated  from  them  by  the  absence  of  febrile 
disturbance,  and  the  necessity  for  actual  contact  in  order  to  its  introduction.  The 
vegetable  and  mineral  poisons  have  no  such  power:  if  life  be  not  destroyed,  and 
the  source  from  whence  they  are  derived  be  cut  off,  in  course  of  time  they  will  be 
eliminated. 


76  DISEASES    OF   ADVENTITIOUS   ORGANS. 

§  1.  Poisons;  properly  so  called. — It  is  not  the  purpose  of  this 
•work  to  enter  on  the  field  of  medical  jurisprudence;  and  therefore 
we  must  content  ourselves  with  a  general  outline  of  the  points  which 
may  serve  to  discriminate  a  case  of  sudden  illness  from  one  of  ordi- 
nary poisoning. 

Much  may  be  learned  regarding  the  nature  of  the  attack,  inde- 
pendently of  ascertaining  the  fact  that  poison  has  been  taken,  by  a 
careful  inquiry  into  the  antecedent  circumstances.  Among  them 
stands,  first,  the  suddenness  of  the  seizure.  We  are  led  to  inquire 
if  there  have  been  any  premonitory  symptoms — any  ailment  prior 
to  its  occurrence ;  how  the  patient  was  last  engaged — whether  he 
had  taken  food,  drink,  or  medicine;  who  was  in  his  company,  &c. : 
and,  in  order  to  be  prepared  to  give  evidence,  if  called  upon,  it  is 
wise  to  mark  every  circumstance  about  the  patient,  anything  re- 
markable in  the  room,  among  the  attendants,  &c. ;  and  to  be  care- 
ful that  nothing  be  thrown  away.  The  order  of  the  phenomena  is 
to  be  noted,  so  far  as  we  can  collect  it  from  the  statements  of  others, 
or  from  our  own  observation. 

His  general  condition  next  occupies  our  attention:  the  absence 
of  fever;  a  condition  of  collapse  or  depression;  of  sickness  or  vo- 
miting; of  pain;  of  excitement  or  delirium;  of  tetanic  spasm  or 
convulsion;  of  unconsciousness,  insensibility,  or  coma.  These  must 
be  contrasted  with  similar  conditions  arising  out  of  various  diseases, 
in  order  to  ascertain  whether  any  sudden  internal  lesion  could  have 
caused  the  group  of  symptoms  presented.  It  is  scarcely  necessary 
to  remark,  that  those  diseases  (e.  g.  cholera)  which  in  the  suddenness 
and  intensity  of  their  attack  resemble  cases  of  ordinary  poisoning, 
may  often  be  discriminated  by  their  epidemic  character.  A  few 
special  indications  of  the  more  important  classes  of  poisons  may  be 
here  pointed  out,  in  order  to  guide  the  student  in  his  investigation 
of  cases  of  this  nature. 

a.  Irritant  poisons  produce  irritation  of  the  mouth,  throat,  and 
stomach.  This  may  amount  to  actual  corrosion,  or^  consist  merely 
m  a  burning  sensation  on  the  tongue  and  constriction  in  the  throat ; 
perhaps  it  may  affect  the  larynx,  causing  hoarseness ;  or  there  may 
be  acute  pain  in  the  stomach,  which  is  afterwards  associated  with 
tenderness  to  the  touch.  The  latter  is  usually  distinguished  from 
peritonitis  following  on  rupture  of  the  stomach  by  its  much  more 
local  character  and  its  lower  degree  of  intensity;  except  .perhaps 
when  a  corrosive  poison  has  been  taken,  and  then  the  indications 
in  the  mouth  and  throat  are  conclusive.  Rupture  of  the  stomach 
most  commonly  follows  upon  a  long  train  of  dyspeptic  symptoms 
indicating  ulceration,  or  a  violent  blow  after  repletion.  Vomiting 
and  diarrhoea  are  usually  the  concomitants  of  irritant  poisoning, 
and  rarely  of  rupture,  except  when  a  fit  of  vomiting  is  its  cause. 
In  both  cases  extreme  collapse  is  very  often  present,  and  then  the 
pain  is  a  less  prominent  symptom;  but  in  those  which  are  caused 
by  poisons,  we  shall  probably  find  other  phenomena  belonging  to 


poisons.  77 

the  nervous  system,  such  as  giddiness,  dazzling  of  the  eyes,  tinnitus 
aurium,  spasms,  cramps,  convulsions,  &c,  because  their  effects  are 
not  clue  simply  to  corrosion,  but  are  produced  by  their  specific  action 
on  the  cerebro-spinal  system,  as  well  as  that  which  they  exert  upon 
the  nerves  and  mucous  membrane  of  the  stomach. 

b.  Narcotics. — These  poisons  affect  primarily  the  nervous  system, 
and,  through  that,  the  circulation;  producing  stupor,  convulsions, 
stertorous  breathing,  depression  of  the  heart,  lividity  of  the  face. 
In  some  there  is  combined  with  this  an  irritating  quality,  and  such 
are  attended  with  the  burning  sensations  in  the  throat  and  fauce3 
peculiar  to  the  irritant  poisons:  if  these  sensations  be  followed  by 
the  supervention  of  nervous  symptoms,  the  diagnosis  is  compara- 
tively easy.  In  poisoning  by  the  simple  narcotics  there  may  be 
more  difficulty  in  arriving  at  a  diagnosis.  Opium  produces  stupor, 
somnolence  with  contracted  pupils,  and  coma.  This  order  of  se- 
quence is  the  best  aid  to  diagnosis,  especially  in  the  absence  of 
convulsions :  the  same  order  is  also  observed  in  cases  of  albuminuria ; 
but  the  symptoms  come  on  more  slowly,  occupying  days  in  place  of 
hours,  except  when  the  coma  is  hastened  by  convulsions,  which  are 
very  common  among  the  head  symptoms  in  Bright's  disease,  and 
are  exceedingly  rare  in  narcotic  poisoning.  This  order  is  exactly 
reversed  in  another  class  of  cases,  which  commence  with  convulsion 
and  terminate  with  prolonged  stupor;  we  shall  have  occasion  to 
refer  to  these  in  speaking  of  serous  and  transient  apoplexy.  If 
the  history  be  unknown,  as  in  a  patient  brought  from  the  street, 
there  are  points  of  time  in  which  the  symptoms  of  the  two  states 
closely  correspond;  the  probable  duration  must  here  be  taken  into 
account,  and  the  rapid  or  gradual  development  of  the  symptoms. 
When,  from  circumstances,  it  appears  probable  that  the  seizure  has 
been  sudden,  a  condition  of  drowsiness,  partial  stupor,  and  unwil- 
lingness to  move,  must  not  be  taken  as  conclusive  of  poisoning  by 
opium.  We  must  refer  to  the  state  of  the  pupils,  which  in  the 
functional  disorder  are  seldom  contracted,  as  they  are  in  the  cases 
of  narcotic  poisoning:  the  condition  of  the  mental  faculties  also 
affords  aid  in  diagnosis,  as  they  are  nearly  natural  when  the  patient 
is  roused  from  the  state  of  narcotism ;  while  there  is  great  confu- 
sion, perhaps  complete  unconsciousness,  of  surrounding  objects  and 
circumstances,  in  one  who  is  suffering  from  epileptic  sopor. 

At  a  further  stage  the  complete  coma  may  closely  resemble  san- 
guineous apoplexy.  Here  we  have  regard  to  the  suddenness  of  the 
seizure,  the  existence  of  any  degree  of  consciousness,  and  the  ab- 
sence or  presence  of  paralysis.  If  the  patient  can  be  roused  at  all, 
and  there  be  no  paralysis,  the  probability  is  in  favour  of  poisoning 
by  opium;  if  the  seizure  appear  to  have  been  sudden,  in  favour  of 
apoplexy.  Equal  contraction  of  both  pupils  points  to  poisoning, 
unequal  contraction  or  dilatation  to  apoplexy.  Intoxication,  when  of 
such  a  degree  as  to  be  classed  among  cases  of  narcotic  poisoning, 
may  generally  be  distinguished  by  the  odour  of  the  breath. 


I 
78  DISEASES    OF   ADVENTITIOUS   ORGANS. 

Hydrocyanic  acid  is  extremely  sudden  in  its  action ;  there  is  less 
of  coma  and  more  of  convulsion  accompanying  the  condition  of 
unconsciousness.  It  very  often  reveals  itself  by  its  powerful 
odour. 

c.  The  gaseous  poisons,  while  they  oppress  the  brain,  producing 
chiefly  a  comatose  state,  also  prevent  the  proper  oxygenation  of  the 
blood,  and  are  therefore  specially  marked  by  lividity  of  face.  The 
place  where  the  person  is  found,  and  the  sense  of  suffocation  expe- 
rienced by  those  who  attempt  to  rescue  him,  seldom  leave  any  room 
for  doubt. 

d.  Sloiv  poisoning. — Attention  has  recently  been  revived  to  this 
mode  of  the  employment  of  poison,  because  of  the  suspicion  that  it 
has  been  carried  to  a  fatal  issue,  in  more  than  one  instance,  with 
impunity.  It  was  supposed  to  have  been  very  generally  practised 
by  the  poisoners  of  former  ages ;  but  the  light  of  science  has  shown 
how  very  few  of  the  poisons  can  be  so  used,  and  how  very  readily 
they  may  be  detected,  if  suspicion  be  only  awakened.  Antimony 
and  arsenic  are  those  which  have  been  recently  employed:  the  for- 
mer may  be  very  readily  disguised;  the  latter  requires  more  inge- 
nuity for  its  concealment.  One  of  the  most  striking  features  of 
the  cases  recorded  was  the  entire  cessation  of  the  symptoms  in  the 
absence  of  a  particular  member  of  the  family;  and  such  a  coinci- 
dence ought,  of  course,  to  arrest  our  attention.  In  the  employment 
of  antimony  many  symptoms  must  be  wanting  which  ought  to  be 
found  in  any  condition  of  stomach  that  could  otherwise  account  for 
the  constant  vomiting  and  extreme  depression.  By  arsenic,  again, 
ulceration  of  the  bowels  is  actually  produced,  and,  therefore,  the 
absence  of  general  indications  is  not  so  distinctive;  but  the  medical 
attendant  may  be  aroused  by  the  presence  of  some  particular  symp- 
toms, such,  for  instance,  as  tingling  sensations  in  the  hands,  which. 
are  recorded  as  among  its  more  constant  concomitants. 

A^egetable  poisons  have  not  been,  and  perhaps  cannot  be,  thus 
employed.  When  introduced  in  small  quantity,  they  appear  either 
to  be  decomposed  or  to  pass  out  of  the  body  without  exerting  their 
poisonous  influence,  while  the  system  gets  accustomed  to  their  pre- 
sence, and  tolerates  them  in  larger  doses.  One  remarkable  excep- 
tion to  this  is  found  in  digitalis,  which,  by  its  continued  administra- 
tion, acquires  a  cumulative  power,  suddenly  acting  as  a  poison  when 
given  for  a  time  as  a  medicine.  Its  effects  then  resemble  an  ordi- 
nary case  of  poisoning  by  digitalis,  and  present  nothing  remarkable 
in  consequence  of  the  slowness  of  its  introduction. 

The  subject  of  slow  poisoning,  as  it  has  received  little  attention, 
requires  at  present  further  study.  It  affords  an  illustration  of  what 
has  been  so  often  urged,  that  in  every  case  our  judgment  must  not 
be  based  on  the  evidence  of  one  single  fact.  The  presence  of  the 
poison  in  the  body,  without  its  usual  symptoms,  except  when  found 
in  a  poisonous  quantity  in  the  stomach  itself,  is  as  unsatisfactory,  in 
a  case  of  sudden  death,  as  the  detail  of  ill-defined  symptoms  with- 


poisons.  79 

out  the  discovery  of  the  poison  in  a  case  of  slow  poisoning:  -whereas, 
a  definite  group  of  symptoms  may  be  enough  to  outweigh  the  nega- 
tive evidence  that  chemistry  has  failed  to  find  the  foreign  substance 
in  the  stomach  or  the  tissues. 

§  2.  Animal  virus. 

a.  Syphilis  and  Gonorrhoea.— Both  of  these,  as  local  disorders,  are  considered  to 
belong  wholly  to  the  province  of  surgery,  and  therefore  no  attempt  will  be  made  to 
give  any  details  on  the  subject,  or  even  to  indicate  the  principles  of  their  diagno- 
sis. They  can  only  be  incidentally  mentioned  when  their  existence  tends  to  ob- 
scure other  phenomena,  or  their  features  present  any  similarity  to  disease  of  a 
wholly  different  origin. 

They  are  separated  from  each  other  by  a  very  broad  line  of  demarkation,  the 
oue  being  merely  a  local  malady,  while  the  other  tends  to  become  constitutional; 
the  one  can,  and  the  other  cannot,  infect  the  system  at  large.  It  is  this  power  of 
the  syphilitic  poison  to  pass  into  the  blood,  and  to  manifest  itself  in  various  tissues 
and  organs,  which  sometimes  brings  it  within  the  cognizance  of  the  physician ;  and 
it  will  be  more  convenient  to  consider  any  special  characters  which  it  presents, 
when  treating  of  the  various  organs  in  which  its  symptoms  usually  show  themselves, 
remembering  only  the  unity  which  comprises  all  these  separate  manifestations,  the 
syphilitic  impregnation.  It  is  often  difficult,  and  yet  not  unimportant  in  practice, 
to  be  able  to  determine  that,  where  primary  syphilis  has  existed  atsome  previous 
period,  the  system  lias  not  become  impregnated;  and,  also,  that  this  poisoning  of 
the  body  has  taken  place  where  the  existence  of  the  primary  malady  is  denied. 

The  decision  rests  chiefly  upon  the  mutual  dependence  and  connexion  of  the 
whole  group  of  the  symptoms ;  the  peculiar  ulceration  of  the  fauces  and  perhaps  of 
the  larynx;  the  specific  characters  of  the  cutaneous  eruptions;  the  very  frequent' 
falling  of  the  hair,  and  the  presence  of  periostial  thickenings;  in  severe  cases,  ca- 
ries of  the  bones  of  the  nose  is  also  present.  The  more  complete  the  picture  is 
as  a  whole,  the  more  confidence  we  feel  in  the  diagnosis:  the  specific  characters 
of  each  may,  singly,  deceive  us.  The  patient's  habits  and  mode  of  life  are  very 
likely  to  throw  light  on  the  question,  when  a  suspicion  of  syphilis  is  denied ;  and 
we  may  form  some  estimate  of  the  probability  from  the  course  of  the  primary  sore, 
where  its  previous  existence  is  admitted:  as  a  general  rule,  we  are  informed  by 
writers  on  this  subject,  that  a  sloughing  or  phagedenic  sore,  or  one  followed  by  a 
suppurating  bubo,  is  less  likely  to  be  followed  by  secondary  symptoms,  than  an 
indurated  chancre. 

The  only  question  we  shall  have  to  consider  with  reference  to  gonorrhoea,  is 
how  we  may  discriminate  it  from  leucorrhcea  and  vaginitis;  the  discussion  of 
which  must  be  reserved  to  the  chapter  devoted  to  the  diseases  of  the  female  organs 
of  generation. 

b.  Hydrophobia. — The  nature  of  this  disease  is  so  little  known,  and  the_ oppor- 
tunities which  each  observer  has  of  studying  it  are  so  few,  that  its  diagnosis  is,  in 
fact,  nothing  else  than  a  knowledge  of  its  whole  history.  We  have  here  no  test  to 
apply  to  the  disordered  functions,  by  which  we  can  measure  the  information  they 
convey,  and  there  is  no  other  condition  which  really  simulates  it,  or  ought  to  be 
mistaken  for  it.  Cases  are  indeed  recorded  in  which  persons  entertaining  a  de- 
lusion that  they  had  been  bitten  by  a  mad  dog,  have  seemed  to  labour  under 
a  similar  disease.  If  the  symptoms  were  really  analogous,  it  is  impossible  to 
say  wherein  this  differed  from  hydrophobia,  except  that  the  bite  of  a  rabid  animal 
was  wanting,  and  that  the  disease  terminated  in  recovery  when  the  delusion  had 
been  successfully  removed.  We  know  only  the  category  of  symptoms,  and  we 
know  absolutely  nothing  more. 

Sometimes  the  bite  is  difficult  to  cure,  is  inflamed  and  irritable:  most  common- 
ly it  seems  to  heal  kindly,  and  only  inflames  at  a  later  period;  but  it  does  not  ap- 
pear that  either  condition  is  necessary  to  the  issue.  Then,  again,  in  ordinary 
cases,  the  dangerous  symptoms  appear  about  six  weeks  after  the  bite;  but  the 
period  that  may  elapse  is,  so  far  as  we  know,  unlimited.  When  they  have  once 
begun,  they  go  on  most  rapidly  to  a  fatal  termination.     First,  there  is  a  general 


80  DISEASES    OF    ADVENTITIOUS   ORGANS. 

feclin"  of  malaise,  a  convulsive  constriction  of  the  throat  in  attempting  to  swallow 
and  slight  acceleration  of  the  pulse;  then  comes  an  instinctive  shudder  at 
ti,,.  |  1  of  any  fluid,  followed  by  a  remarkable  erethism  of  the  nervous 

n.  which  produces  spasmodic  contractions  of  the  muscles,  especially  about 
the  throat  and  larynx,  and  convulsive  paroxysms  at  the  least  jarring  noise  or  sud- 
den movement.  In  this  condition  the  patient  is  especially  excited  by  currents  of 
air  on  any  part  of  the  body;  and  the  spasms  may  be  thus  renewed  even  afterdeath. 
At  last,  the  unhappy  victim  of  this  frightful  malady  becomes  violently  delirious, 
and  rapidly  exhausted;  and  he  either  expires  in  the  recurrence  of  convulsions,  or 
more  frequently  becomes  tranquil  before  death,  and  sinks  pulseless  and  exhausted. 
A  peculiarity  which  attends  most  cases  of  hydrophobia,  the  constant  hawking  and 
spitting  up  of  adhesive  mucus  and  saliva,  was,  at  one  time,  fancifully  interpreted 
into  an  imitation  of  the  bark  of  a  dog;  it  simply  depends  upon  inability  to  swal- 
low and  irritation  in  the  throat,  the  act  being  performed  in  a  peculiar  manner  in 
consequence  of  delirium:  as  in  insanity,  the  patient  bespatters  indifferently  the 
bed-clothes  and  the  floor,  or  even  the  attendants,  with  his  expectoration.  The  in- 
clination to -bite  seems  purely  mythical. 

There  are  only  two  points  which  call  for  especial  notice  with  reference  to  diagno- 
sis :  first,  the  instinctive  dread  of  liquid  is  to  be  distinguished  from  a  delusion ;  it  is 
really  occasioned  by  the  spasmodic  difficulty  in  swallowing,  and  only  presents  any 
character  of  a  mental  hallucination  when  delirium  has  supervened.  Secondly,  the 
convulsive  movements  must  not  lead  us  away  from  hydrophobia  to  epilepsy  and 
tetanus;  they  really  have  no  close  analogy  to  it,  as  the  case  presents  neither  the 
unconsciousness  of  the  one,  nor  the  permanent  spasm  of  the  other.  Strychnia 
poisoning  resembles  hydrophobia  in  the  excitability  or  erethism  of  the  nerves  con- 
nected with  the  voluntary  muscles,  but  in  nothing  else;  it  cannot  really  simulate 
the  disease. 

c.  Glanders,  or  Acute  Farcy— k  disease  well  known  to  veterinary  surgeons  in 
its  chronic  as  well  as  in  its  acute  form,  would  seem,  in  rare  cases,  to  be  transferred 
to  man;  in  the  human  subject  it  is  always  acute,  and  rapidly  fatal.  _  In  its  gene- 
ral features  it  resembles  so  much  the  effects  following  upon  the  condition  of  pyae- 
mia, that  it  might  admit  of  question  whether  the  symptoms  are  not  really  rather 
due  to  this  circumstance  than  to  any  specific  character  of  the  poison  itself,  were 
it  not  that  in  one  or  two  essential  points  it  seems  to  differ. 

The  history  of  the  case  records  the  very  speedy  supervention  of  the  disease 
without  any  previous  ailment,  and  sometimes  without  any  adequate  cause  being 
assigned;  and  the  social  condition  of  the  patient,  indicating  his  being  employed 
am  oil  g  horses,  may  serve  to  suggest  a  solution  of  a  setof  anomalous  symptoms, 
which,  as  they  are  so  rarely  seen,  can  seldom  be  recognised  by  practitioners  from 
experience.  Most  of  our  students  must  have  finished  their  hospital  attendance 
without  having  seen  a  case  of  glanders. 

The  symptoms  are  those  of  fever  of  a  low  type,  accompanied  by  inflammation 
of  the  glands  which  rapidly  suppurate,  forming  red  and  painful  swellings  over 
various  parts  of  the  body;  these  terminate  in  pustules  of  some  size,  surrounded 
by  a  red  line,  which  is  again  bounded  by  a  white  wheal:  they  stand  in  connexion 
with  inflamed  lymphatics,  which  may  sometimes  be  traced  along  their  course. 
The  disease  almost  invariably  ends  with  ulceration  of  the  mucous  membrane,  and 
fetid  discharge  from  the  nose,  and  occasionally  this  is  one  of  the  earliest  symptoms. 
Sometimes  its  course  is  not  so  defined,  and  it  may  be  first  recognised  by  the  for- 
mation of  oue  or  more  abscesses  of  some  size;  this  is  probably  explicable  on  the 
ground  that,  though  the  lymphatic  system  is  that  primarily  affected,  the  symptoms 
in  such  cases  are  rather  due  to  an  altered  condition  of  the  blood,  acting  through 
the  capillaries.  The  inflamed  glands  correspond  to  what  farriers  are  in  the  habit 
of  calling  "  farcy  buds ;"  the  abscesses  are  more  properly  what  in  medical  language 
have  been  denominated  "  secondary  depots  ;"  they  form  in  similar  situations,  and, 
as  has  been  already  noticed  in  speaking  of  acute  rheumatism,  the  joints  are  espe- 
cially liable  to  become  the  seat  of  local  swelling  and  inflammation. 

§  3.   Colica  Pictonum—Vfhile  having  acquired  for  itself  a  par- 
ticular name  by  its  distinctive  characters,  and  presenting  a  very 


COLICAFICTONUM.  81 

well  defined  group  of  symptoms,  the  disease  of  which  we  have  now 
to  speak  is  in  truth  nothing  else  than  a  form  of  slow  poisoning. 
The  history  of  its  discovery  affords  a  very  happy  illustration  of  the 
value  and  uses  of  correct  diagnosis,  and  of  the  manner  in  which  it 
may  be  made  subservient  to  the  real  progress  of  medical  science. 

Painters'  colic,  as  is  now  well  known,  is  due  to  the  absorption  of 
lead.  The  disease  is  gradually  developed,  gaining  intensity  with 
every  fresh  addition  to  the  poison  already  accumulated  in  the 
system;  its  symptoms  are  in  great  measure  local,  and  any  pecu- 
liarities they  may  individually  present  must  be  again  referred  to, 
at  present  we  have  only  to  consider  them  as  parts  of  the  whole. 

The  preliminary  inquiry  into  the  age  and  social  position  of  the 
patient,  or  some  particular  in  his  history,  may  afford  information 
that  he  has  been  exposed  to  the  influence  of  the  poison ;  in  other 
respects  we  learn  nothing  except  the  occurrence  of  occasional  con- 
stipation with  colicky  pains.     The  first  severe  attack  is  usually  of 
colic:    there    is  nothing,  however,  specific    in    its  character;   the 
tongue  is  generally  somewhat  furred,  and  the  bowels  obstinately 
confined;  there  is  no  acceleration  of  pulse;  and  the  skin  is  inclined 
to  be  cold  from  the  prostration  caused  by  a  tearing,  grinding  pain, 
as  opposed  to  a  stitch — a  sharp  or  darting  pain ;   the  abdomen  may 
be  full  and  tympanitic,  but  it  is  not  tense  or  tender,  and  is  often 
retracted :  pressure  rather  relieves,  while  motion  does  not  aggravate 
it,  and,  therefore,  in  place  of  lying  motionless  with  his  knees  drawn 
up,  the  patient  rolls   and  tosses  about  in  bed.     The  history,  if  it 
fail  to  point  out  the  source  of  impregnation,  yet  assists  the  dia- 
gnosis by  excluding  other  affections  of  a  non-inflammatory  charac- 
ter,  of  which  pain  in  the  abdomen  is  a  prominent  symptom.     It 
indicates  that  the  disorder  has  come  on  gradually,  and  thus  ex- 
cludes the  possibility  of  some  undigested  or  unwholesome  food, 
recently  taken  acting  as  the  cause  of  colic ;  it  not  only  refers  to 
previous  attacks  of  less  severity,  but  also  to  the  gradual  increase 
of  pain  during  the  present  illness:    these    circumstances,  taken 
along  with  the  diffused  character  of  the  pain,  render  it  less  liable 
to  be  confounded  with  that  attending  the  passage  of  gall-stones ; 
while  the  knowledge  of  previous  constipation  or  sluggishness   of 
bowels    excludes    the  possibility  of  diarrhoea.      In  patients  thus 
affected,  a  blue  line  is  generally  found  along  the  edges  of  the  gums, 
which  when  well  marked  is  very  conclusive.     Something  similar  is 
often  seen,  when  there  is  no  evidence  of  lead-poisoning,  among  the 
lower  orders,  whose  teeth  are  encrusted  with  tartar;  and  a  red  line 
is  believed  by  some  to  exist  very  constantly  in  cases  of  phthisis. 
These  cannot  lead  to  mistakes  if  the  lead  line  has  been  carefully 
observed  in  marked  cases ;    and  the  presence  of  other  symptoms 
can  alone  justify  us  in  calling  the  case  one  of  colica  Pictonum. 

In  a  more  advanced  form  of  the  disease  paralysis  is  observed, 
especially  affecting  the  extensor  muscles  of  the  fingers  and  wrists ; 
sometimes  limited  to  those  of  one  or  two  fingers,  especially  the 
6 


ENTOZOA. 

rod,  third  ;ind  fourth,  but  more  generally  implicating  all  the 

>rs.     This  affection,  commonly  known  as  "drop-wrist,"  may 

met  with  occasionally  without  the  prior  appearance  of  colic  ;  this 

.  however,  and  is  chiefly  seen  in  cases  in  which  the  lead  has 

n  introduced  exceedingly  slowly.    In  its  last  stages,  the  general 

health  also  suffers,  and  there  is  sometimes  considerable  emaciation; 

the  poison  tells  upon  the  brain,  producing  epileptic  seizures.  &e., 

and  a  well  marked  condition  of  general  cachexia  is  established. 

Division  II. — Extozoa. 

A  class  of  disorders  is  next  to  be  noticed,  which,  like  the  pre- 
ceding, owe  their  existence  to  the  presence  of  a  cause  which  is 
wholly  adventitious,  and  is  cognizable  to  the  senses,  but  differs 
from  them  in  this  respect — that,  in  place  of  depending  on  the  pre- 
sence of  foreign  animal  or  vegetable  matter,  or  of  some  mineral 
poison,  their  symptoms  arc  due  to  the  presence  of  a  parasitic  ani- 
mal, living  not  upon  the  surface  of,  but  within  the  human  body, 
having  a  distinct  and  separate  existence,  and  endowed  with  certain 
powers  of  reproduction. 

The  chief  point  to  be  noticed  in  regard  to  diagnosis  is  that  the 
symptoms  alone  cannot  be  taken  as  conclusive  evidence  of  their  pre- 
sence ;  and,  however  distinct  the  indications  may  appear,  we  are 
not  justified  in  asserting  that  they  have  this  cause  until  specimens 
of  the  parasite  have  been  seen. 

Two  divisions  only  of  this  class  are  included  in  the  table  of  dis- 
eases, because  the  others  are  comparatively  rare  and  unimportant ; 
and,  it  may  be  remarked,  that  these  present  special  sources  of  in- 
terest, with  reference  to  diagnosis ;  because  of  their  relations  to 
other  forms  of  disease:  they  are  the  intestinal  entozoa  and  the 
echino-coccus  hominis ;  the  latter  closely  connected  with  the  occur- 
rence of  hydatids,  the  former  a^ociated  with  disorders  of  the  di- 
gestive organs, 

§  1.  JEcldno-coccus — Within  a  very  recent  period,  careful  obser- 
vation has  proved  that  this  creature  is  only  a  transformation  or 
stage  of  development  of  the  taenia,  and  this  in  some  measure  ac- 
counts for  its  comparative  frequency.  The  discovery  is  pregnant 
with  interest  to  us  as  physiologists;  but,  as  physicians,  we  are 
more  concerned  with  the  very  different  habitat  of  the  animal  in  its 
two  extremely  dissimilar  conditions  of  existence.  In  the  form  we 
are  now  considering  it  is  found  in  hydatid  cysts,  and  would  seem 
to  be  in  some  way  concerned  in  their  production.  We  have  not  yet 
learned  to  recognise  the  distinction  between  the  acephalo-cyst,  in 
which  this  parasite  is  present,  and  those  in  which  it  has  not  been 
found  after  death  ;  and,  therefore,  the  question  of  diagnosis  is 
limited  to  the  recognition  of  the  existence  of  the  cyst,  except  in 
rare  cases,  in  which  its  contents  are  evacuated  and  the  echino- 
coccus  seen  during  life.     Any  points  of  interest  will,  therefore,  be 


ENTOZOA.  83 

recorded  when  we  come  to  the  consideration  of  cysts  as  one  of  the 
forms  of  morbid  growth. 

§  2.  Intestinal  Worms  present  themselves  in  three  principal 
forms,  as  broad  or  tape-worms,  round  worms,  and  thread-worms. 

a.  Tape-worms,  so  named  from  their  appearance,  are  discharged 
as  a  number  of  flat  fragments  of  various  lengths,  crossed  by  trans- 
verse joints,  where  separation  is  liable  to  take  place,  and  each  por- 
tion of  the  animal  which  is  discharged  has,  consequently,  a  square 
termination.  They  are  of  two  species: — 1.  Taenia  solium,  marked 
by  notches  on  either  side,  irregularly  alternating  along  the  edges 
of  the  flat  body,  one  of  which  occurs  between  every  two  joints,  and 
is  situated  rather  nearer  to  the  lower  than  to  the  upper  one.  2. 
Tsenia  lata,  or  Bothrio-cephalus  lotus,  marked  by  a  line  of  depres- 
sions, one  for  each  segment,  running  down  the  centre  of  one  of  the 
flat  sides  of  the  parasite. 

Their  presence  is  apt  to  be  overlooked  because  they  give  rise 
only  to  such  symptoms  as  may  readily  be  regarded  as  those  of 
dyspepsia; — pain  of  a  gnawing  character  at  the  epigastrium,  unea- 
siness after  food,  cough  and  headache,  usually  accompanied  by  a 
craving  appetite;  the  patient  is  out  of  health,  and  generally  some- 
what emaciated.  This  craving  is  to  be  distinguished  from  the 
large  consumption  of  food  which  sometimes  accompanies  emaciation 
in  the  course  of  a  wasting  disease,  when  the  digestive  apparatus  has 
not  been  deranged;  and  also  from  the  ravenous  appetite  of  diabetes. 
In  the  former  there  is  no  disorder  of  the  intestinal  canal,  in  the 
latter  there  is  thirst  as  well  as  hunger:  when  the  symptom  depends 
on  the  presence  of  tape-worm,  there  is  always  derangement  of  the 
digestive  organs,  and  the  sensation  is  one  of  craving  rather  than  of 
hunger. 

The  diagnosis  is  only  complete  when  portions  of  the  worm  come 
away  with  the  feces.  Their  shape,  as  each  small  segment  is  more 
or  less  elongated  in  proportion  to  its  breadth,  enables  us  to  form  an 
idea  of  the  length  of  the  entire  worm:  when  they  are  lono-  and 
broad,  we  may  conclude  that  it  is  of  considerable  length ;  when  short 
and  broad,  the  remaining  portion  is  probably  not  great;  when 
narrow  as  well  as  short,  the  fragments  come  away  from  near  its 
head  or  fixed  extremity.  It  is  a  curious  circumstance,  in  regard  to 
the  two  species  of  fenia,  that  they  relatively  abound  more  in  cer- 
tain localities;  the  bothrio-cephalus  is  usually  imported  into  this 
country,  and  is  soon  expelled  from  the  body,  while  the  solium 
among  us  lives  and  thrives. 

b.  Round  worms  {lumbrici,)  seldom  solitary,   are  chiefly  lodged 
in  the  small  intestines,  where  their  presence  does  not  seem  to  give 
rise  to  any  very  marked  symptoms ;    occasionally,  however,  they 
are  productive  <af  mischief  by  wandering  into  the  appendix  coeci 
the  gall-duct  <sf  the   stomach;  and,  when  lodged  high  up  in  the 

canal  in  childhood,  are  apt  to  give  rise  to  convulsive  affections 

both  chorea  and  epilepsy. 


84  E  N  T  0  Z  0  A  . 

c.  Thread  worms  (ascarides)  are  found  sometimes  in  enormous 
numbers,  and  reside  chiefly  in  the  rectum.  They  are  very  common 
in  children,  and  produce  irritation  of  the  mucous  membrane,  as 
shown  in  picking  the  nose,  scratching  the  anus,  &c. :  sometimes 
they  crawl  into  the  vagina  and  cause  much  annoyance.  It  does 
not  appear  that  they  give  rise  to  any  derangement  of  health,  but 
they  are  commonly  associated  with  depraved  states  of  the  aliment- 
ary canal  and  unhealthy  secretions. 

Another  intestinal  worm  might  be  mentioned,  the  Tricliocepludus  dispar,  but 
that,  it  does  not  seem  to  be  associated  with  any  morbid  phenomena,  and  when  passed 
would  be  readily  taken  for  an  ascaris.  For  similar  reasons  we  have  not  alluded 
to  the  various  forms  of  fUaria,  one  of  which,  the  "guinea-worm/'  is  seldom  seen 
in  this  country;  nor  to  the  Trichina  spiralis,  sometimes  found  in  the  voluntary 
muscles;  nor  to  the  distoma,  which,  as  the  "liver-fluke,"  is  so  common  in  sheep; 
or  the  cysticercus,  which  in  the  pig  produces  what  is  called  "  measly  pork."  The 
last  two' are  more  rarely  met  with  in  the  human  species.  The  Strongj/his  gigas, 
found,  I  believe,  only  in  the  kidney,  may  be  the  cause  of  various  symptoms  refer- 
rible  to  the  disintegration  and  absorption  of  the  organ,  but  cannot  be  iu  any  way 
diagnosed  during  life. 


85 


CHAPTER   VII. 

DISEASES    OF    UNCERTAIN    OR    VARIABLE    SEAT. 

Div.  I. — Dropsies. — §  1,  Anasarca  the  Type  of  General  Dropsy — 
Acute — Chronic — Local  (Edema — §  2,  Ascites — Association  with 
Anasarca — Detection — Causes. 

Div.  II. — Hemorrhages. — §  1,  Epistaxis — §  2,  Hemoptysis — 
Causes  and  Associations — §  3,  Hcematemesis — Characters  and 
Causes — §  4,  Hcematuria — §  5,  Intestinal  Hemorrhage — §  6, 
Uterine  Hemorrhage. 

The  somewhat  indefinite  heading  of  this  chapter  has  been  adopted  from  the 
classification  of  the  Registrar-General,  for  the  purpose  of  grouping  together  some 
diseases  which,  while  they  cannot  be  included  among  such  as  owe  their  origin  to 
a  morbific  or  adventitious  impregnation,  at  the  same  time  cannot  be  readily 
classified  under  the  diseases  of  particular  organs,  because  of  the  variable  nature 
of  their  cause  and  their  seat.  In  the  order  which  we  have  prescribed  to  ourselvc  s 
they  must  be  considered  here,  because  their  symptoms  are  among  the  objective 
phenomena  of  disease,  and  each  division  presents  one  prominent  feature  common 
to  the  whole  groupl 

In  a  strictly  scientific  point  of  view,  it  may  be  alleged  that  they  ought  to  be 
studied  simply  as  symptoms ;  but  for  the  purpose  of  diagnosis  they  must  be  con- 
sidered in  their  relation  to  each  other,  as  we  shall  thus  be  enabled  to  compare 
their  extent  and  situation,  and  to  ascertain  with  more  exactness  the  deductions 
which  they  warrant  with  reference  to  internal  organs.  The  classification  which 
separates  them  from  the  deeper  seated  disease  is  justified  by  the  circumstance  that 
they  may  be  the  only  definite  symptom  of  its  presence ;  they  are  the  subjects  of 
complaint  and  the  object  of  treatment,  and  it  is  only  by  inference  that  we  are  led 
to  suspect  the  existence  of  anything  more. 

They  also  differ  from  mere  symptoms  in  presenting  decided  and  broadly  marked 
characters,  which  are  uniform  and  consistent,  whatever  be  their  situation  or  sup- 
posed cause.  They  do  not  necessarily  accompany  the  more  important  lesions 
with  which  they  are  usually  associated,  but  seem  only  to  supervene  under  certain 
circumstances,  of  which  the  most  important  probably  is  an  altered  condition  of 
the  blood  itself.  Further,  although  they  are  most  frequently  dependent  on  some 
form  of  organic  lesion,  yet  occasionally  the  very  same  appearances  may  be  ob- 
served when  the  disorder  is  solely  in  the  circulating  fluid  itself,  and  thus  they  be- 
come allied  with  what  we  have  called  the  chronic  blood-ailments. 

Our  inquiry  will  here  be  limited  to  their  distinguishing  features,  pointing  out 
wherein  they  resemble  or  differ  from  each  other  in  situation  and  appearance;  and 
indicating  only  in  a  general  manner  their  probable  causes.  The  more  minute 
examination  of  the  diseases  with  which  they  are  allied  must  be  deferred  till  we 
come  to  the  consideration  of  those  organs  in  which  they  are  situated. 

Division  I. — Dropsies. 

Increase  of  size  has  been  mentioned  as  one  of  the  objective 
phenomena  of  disease,  with  especial  reference  to  its  frequent  de- 
pendence on  the  presence  of  dropsy.  This  condition  may  be  de- 
fined as  consisting  in  the  effusion  of  fluid,  either  throughout  t1  s 
general  areolar  tissue,  or  within  some  cavity.     But  it  is  not  possible 


86  DISEASES    OF    VARIABLE    SEAT. 

to  regard  every  local  effusion  as  a  disease  of  uncertain  or  variable 
B  sat,  or  as  one  arising  out  of  a  general  condition  of  system;  and 
it  is  therefore  important  to  note  its  simultaneous  occurrence  in 
more  than  one  locality,  as  giving  more  certain  evidence  of  the 
ration  of  general  causes.  Anasarca  will,  for  this  reason,  be 
taken  ;is  the  type  of  general  dropsy. 

The  local  accumulations  of  fluid  which  occur  in  association  with 
the  general  disease,  are  as  numerous  as  the  serous  sacs  which  are 
found  in  all  the  great  cavities,  and  it  is  not  our  business  here  to 
enumerate  them ;  they  are  to  be  viewed  as  merely  subordinate  to 
anasarca.  Local  effusions,  on  the  other  hand,  limited  to  one  serous 
membrane,  must  be  excluded  from  our  consideration  at  present,  as 
they  are  only  of  value  in  so  far  as  they  prove  the  previous  existence 
of  inflammation.  An  exception  must,  however,  be  made  with 
regard  to  ascites,  which  is  less  frequently  a  consequence  of  inflam- 
mation, and  acknowledges  at  least  more  than  one  cause  for  its  pro- 
duction. 

Serous  cysts  are  a  very  common  cause  of  local  dropsy:  they  will 
be  considered  under  the  head  of  morbid  growths ;  that  connected 
with  the  ovaries  alone  being  referred  to  here,  as  it  is  important  to 
point  out  the  characters  by  which  it  is  known  from  ascites. 

§  1.  Anasarca. — Marked  by  painless  swelling,  which  is  free  from 
the  redness  of  inflammation,  except  in  so  far  as  tension  produces 
tenderness  of  the  skin;  it  receives  and  retains  the  mark  of  the 
finger  when  pressure  is  made.  General  dropsy  is  very  frequently 
associated  with  disease  of  the  heart  or  of  the  kidney ;  so  much  so, 
indeed,  that  these  organs  must  be  carefully  examined  in  all  cases 
of  anasarca. 

When  such  an  association  is  made  out,  the  disease  is  very  often  called  cardiac 
or  renal  dropsy;  but  these  terms  are  objectionable,  because  both  organs  are  often 
found  simultaneously  affected,  and  the  relations  which  they  express  convey  an 
idea  of  causation  which  is  not  true.  There  are  various  points  of  detail  in  which 
the  dropsy  principally  associated  with  cardiac  disease  differs  from  that  of  renal 
disease ;  these  will  be  learned  by  experience,  and  give  a  certain  readiness  in  dia- 
gnosis, but  are  not  altogether  trustworthy,  and  can  only  have  value  when  taken  in 
connexion  with  a  more  extended  examination.  Among  these,  the  complexion 
of  the  patient  is  the  consideration  of  most  moment,  because  of  its  bearing  on  treat- 
ment; whether  it  be  dusky  and  bloated,  or  pale,  waxy,  and  ex-sanguine.  All  the 
intermediate  conditions  will  be  found  in  cases  of  dropsy  with  disease  of  these  or- 
gans; but,  while  the  one  extreme  indicates  obstruction  to  the  venous  circulation, 
the  other  marks  deterioration  of  the  blood,  and  thus  they  point  to  the  heart  and 
the  kidney  respectively  as  the  chief  seat  of  disease. 

The  next  consideration  has  reference  to  the  extent  of  the  effusion, 
whether  the  anasarca  be  universal  or  local.  The  effused  serum 
necessarily  tends  to  gravitate  towards  the  most  depending  parts; 
and  this  is  aided  in  the  erect  posture,  by  the  weight  of  the  column 
of  blood  pressing  with  greater  force  on  the  capillaries  of  the  lower 
extremities:  limitation  to  the  feet  and  ankles  must,  therefore,  be 


DROPSIES.  87 

excluded  from  the  idea  of  localization,  except  when  one  leg  only  is 
cedetnatous. 

The  history,  again,  divides  the  cases  into  those  in  which  it  has 
come  on  suddenly,  and  those  in  which  it  has  been  more  gradually 
developed,  disappearing  and  reappearing  during  a  long  period,  or 
steadily  increasing  from  the  time  it  was  first  observed. 

a.  The  sudden  form,  or  acute  dropsy,  generally  arises  from  ex- 
posure to  cold,  and  is  very  common,  either  with  or  without  exposure, 
as  a  sequel  of  scarlatina ;  the  urine  is  very  often  albuminous,  but 
not  always  so.  When  albuminuria  is  present,  disease  of  the  kidney 
sometimes  seems  to  commence  in  such  an  attack,  from  which  the 
patient  never  thoroughly  recovers ;  more  commonly,  the  appearance 
of  albumen  in  the  urine  is  quite  transient,  merely  indicating  con- 
gestion ;  on  the  other  hand,  acute  dropsy  with  albuminuria  may  be 
the  first  evident  symptom  of  disease  of  the  kidney.  When  unas- 
sociated  with  albuminuria,  it  probably  depends  on  a  slight  degree 
of  capillary  phlebitis,  causing  retardation  of  the  cutaneous  circula- 
tion: it  is  then  accompanied  by  a  febrile  state,  and  may  be  the 
direct  consequence  of  checked  perspiration,  or  of  the  exposure 
which  produced  this  effect.  The  same  condition  of  the  cutaneous 
capillaries  probably  accompanies  the  kidney  congestion  in  all  cases 
where  fever  is  present.  If  the  exciting  cause  be  more  local,  and 
its  action  more  intense,  diffuse  cellular  inflammation  is  set  up  in 
place  of  anasarca;  the  two  diseases  are  thus  pathologically  allied 
though  presenting  appearances  totally  distinct. 

b.  Chronic  Dropsy  is  that  which  more  usually  attends  upon 
cardiac  or  renal  disease.  We  also  find  either  oedema  of  the  feet 
and  ankles,  or  still  more  general  anasarca,  depending  simply  upon 
deterioration  of  the  blood,  with  excess  of  serum. 

Of  this,  the  most  common  causes  are: — 1.  Exhausting  diseases 
— phthisis,  cancer,  chronic  bronchitis  (when  not  acting,  as  it  com- 
monly does,  through  the  medium  of  the  heart,  the  first  part  of  the 
circulatory  apparatus  affected  by  obstruction  in  the  lungs,)  disease 
of  the  liver,  especially  when  associated  with  ascites.  2.  Want  of 
food,  or  improper  nutrition.  3.  General  poverty  of  blood,  as  in 
aniemia  and  chlorosis.  The  diagnosis  of  these  disorders  will  be 
considered  in  their  proper  places  in  the  sequel ;  but  we  may  learn, 
from  their  number  and  variety,  how  false  is  that  theory  which  is 
expressed  in  the  terms  cardiac  and  renal  dropsy.  Disease  of  either 
organ  may  aid  in  its  production,  but  probably  in  every  case  blood 
changes  must  have  occurred  before  the  serum  exudes  through  the 
coats  of  the  capillaries. 

c.  When  local,  the  term  oedema  is  more  commonly  applied  than 
anasarca.  The  cause  must  be  referred  to  some  obstruction  to  the 
returning  current  of  the  blood,  pressure  on  the  veins  from  without, 
or  occlusion  from  within: — an  unnatural  condition  of  the  parts 
through  which  the  venous  trunk  passes,  or  inflammation  of  its  in- 
ternal coat.     The  extent  of  surface  oedematous,  and  a  reference  to 


->  DISEASES    OF    VARIABLE    SEAT. 

the  distribution  of  its  blood-vessels,  will  greatly  aid  in  determining 
in  what  portion  of  its  current  the  blood  is  obstructed.  Acute 
phlebitis  is  almost  always  associated  with  oedema,  but  the  occlusion 
may  also  be  one  of  long  standing.  "When  obstruction  is  produced 
by  pressure,  and  its  cause  is  situated  externally  to  the  great  cavities 
of  the  chest  and  abdomen,  the  diagnosis  must  be  extremely  simple; 
but  when  the  pressure  is  occasioned  by  some  tumour  lying  within, 
it  is  oftentimes  made  out  only  with  extreme  difficulty,  and  by  very 
careful  examination. 

Local  oedema  also  accompanies  inflammations  of  limited  extent, 
whether  in  the  skin,  such  as  erythema  and  erysipelas,  or  the  diffuse 
inflammation  of  the  cellular  tissue,  or  even  suppurations  of  the 
bones,  joints,  and  ligaments;  and  cases  will  occur  in  which  it  is 
difficult  to  determine  whether  the  inflammation  of  the  skin  and 
cellular  tissue  have  been  caused  by  some  irritation  of  a  limb  already 
tense  from  oedema,  or  the  effusion  of  serum  have  been  the  conse- 
quence of  the  local  inflammation. 

§  2.  Ascites. — Depending,  as  has  been  stated,  upon  more  than 
one  cause  as  its  source,  and  demanding  treatment  often  distinct  from 
that  of  the  disease  from  which  it  springs,  ascites  claims  our  notice 
when  it  is  either  unassociated  with  anasarca,  or  itself  forms  much 
the  most  prominent  feature  of  a  case  in  which  there  is  more  or  less 
general  dropsy.  In  rare  instances,  too,  it  appears  to  have  sprung 
from  some  transient  morbid  state,  and  to  persist  merely  because  the 
accumulation  of  fluid,  by  its  pressure,  prevents  the  due  action  of 
the  absorbent  and  eliminating  process  by  which  it  might  be  removed. 

"When  associated  with  anasarca,  it  is  very  important  to  determine 
whether  it  is  to  be  classed  as  one  of  the  many  local  effusions  which 
acknowledge  the  same  general  causes;  or  as  having  an  independent 
origin  and  cause,  which  simply  co-exists  with  the  others;  or,  lastly, 
■whether  the  anasarca  may  not  itself  be  only  the  consequence  of  the 
ascites.  The  history,  if  absolutely  correct,  would  always  decide 
the  first  and  last  of  these  questions,  especially  if  taken  in  connexion 
with  the  inquiry,  which  ought  never  to  be  omitted,  into  the  several 
conditions  of  system  usually  associated  with  general  dropsy.  "When 
these  have  been  for  some  time  in  operation,  and  oedema  has  been 
observed  distinctly  prior  to  effusion  into  the  abdominal  cavity,  the 
presumption  is  strong  that  ascites  is  merely  casual  and  coincident, 
an  evidence  of  a  general  tendency.  When,  on  the  other  hand,  fluid 
has  been  first  detected  in  the  peritoneum,  and  the  more  commonly, 
acknowledged  causes  of  anasarca  are  absent,  it  is  highly  probable 
that  an  oedematous  state  of  the  lower  limbs  is  caused  only  by 
obstruction  to  the  returning  column  of  blood  through  the  distended 
cavity,  in  an  impoverished  state  of  system.  Unfortunately  it  very 
often  happens  that  accumulations  either  of  flatus  or  of  feces  are 
mistaken  for  dropsical  swelling,  or  that  the  enlargement  of  the 
abdomen  is  not  taken  notice  of  until  after  anasarca  has  supervened: 


DROPSIES.  89 

it  is,  therefore,  very  generally  necessary  to  inquire  into  the  causes 
of  each  condition  separately,  and  not  to  rest  satisfied  -with  the 
hypothesis  that  they  are  both  part  of  the  same  disease. 

To  a  certain  extent,  information  may  be  acquired  from  the 
history  of  the  case,  regarding  the  causes  and  progress  of  ascites ; 
because  we  either  learn  that  it  has  been  preceded  by  pain  in  some 
part  of  the  abdomen,  or  that,  to  the  patient's  own  consciousness, 
there  has  been  nothing,  but  a  gradually  increasing  fulness  and 
tension.  The  history  also  enables  us  to  exclude  local  enlargements 
which  have  been  first  observed  in  some  particular  region  of  the 
abdomen;  and  affords  prima  facie  evidence  of  the  case  being  one 
of  ascites  depending  on  disease  of  the  liver,  when  the  patient  has 
been  a  person  of  intemperate  habits,  or  has  had  an  attack  of  jaun- 
dice. 

The  presence  of  fluid  is  learned  from  the  existence  of  fluctuation ; 
by  which  is  meant  the  sensation  conveyed  to  the  hand,  across  the 
abdomen,  by  a  wave-like  movement  through  the  fluid,  of  a  blow 
struck  at  a  distant  point.  The  accurate  determination  of  this  fluid- 
motion  requires  much  care  and  frequent  practice:  the  extreme 
mobility  of  the  contents  of  the  abdomen,  or  an  accumulation  of  fat 
which,  at  the  temperature  of  the  body,  is  in  a  semi-fluid  state,  are 
each  liable,  in  certain  circumstances,  to  give  rise  to  a  sense  of  resi- 
lience, extremely  like  the  feeling  of  fluctuation.  On  the  other 
hand,  the  intervention  of  a  portion  of  bowel  distended' with  gas 
may  annul  the  wave  of  fluctuation  when  fluid  is  really  present. 
The  first  step  in  the  examination  of  a  distended  abdomen  ought  to 
be  to  place  the  patient  flat  on  the  back,  and  observe  the  general 
contour  of  the  abdomen,  and  then  to  proceed  to  determine  by  per- 
cussion the  position  of  bowel  resonance;  next,  to  seek  for  evidence 
of  fluid  where  that  resonance  ceases  or  is  greatly  diminished, 
observing  how  far  the  fluctuation  extends  in  various  directions  from 
the  part  struck;  and,  lastly,  by  change  of  posture  to  satisfy  our- 
selves as  to  the  relations  of  the  fluid  to  the  other  abdominal  con- 
tents, whether  it  be  freely  moveable  or  comparatively  fixed  in  one 
locality.  And,  having  made  out  to  our  own  satisfaction  that  fluid 
is  present  within  the  cavity  of  the  peritoneum,  we  may  then,  from 
a  consideration  of  the  whole  history  of  the  case,  the  various  symp- 
toms which  have  attended  the  origin  and  progress  of  the  disease, 
and  the  present  condition  of  the  patient,  form  some  idea  of  its 
cause.  And,  if  we  would  avoid  false  deductions  and  injudicious 
treatment,  the  actual  state  of  all  the  organs  of  the  abdomen  must 
b»  analyzed  with  great  care. 

The  history  of  the  case  affords  more  assistance  in  determining  the  particular 
cause  of  the  effusion  than  in  assuring  us  of  its  locality,  except  when  it  speaks 
positively  of  local  enlargement.  And  here  a  caution  may  be  offered  to  students 
that  they  guard  against  either  confounding  for  themselves,  or  leading  the  patient 
to  confound,  pain  for  enlargement;  a  mistake  which,  in  my  own  experience,  has 
led  careless  observers  astray.     Patients  are  very  generally  first  conscious  of  ab- 


00  DISEASES    OF    VARIABLE    SEAT. 

(luminal  tension  by  a  feeling  of  fulness  at  the 'waist;  and  Loth  sexes  will  alike  as- 
Berl  that  their  increase  of  size  l>e:-;il>  there,  when  we  are* perfectly  certain  that  the 
fluid  was  at  the  time  collecting  in  the  lower  part  of  the  abdomen. 

The  patient's  .statement  of   local   enlargement  may  he  often  verified  by  the 
liar  shape  which  the  abdomen  presents  in  the  horizontal  posture:  in  ascites  it 
ually  uniform.     Percussion  resonance  determines  the  relative  position  of  the 
tine,  iu  which  gas  is  almost  always  present,  and  the  foreign  substance,  what- 
ever it  may  be.     It  may  indicate  a  distinct  level  line  all  round  to  which  fluid  rises, 
or  it  may  Bhow  that  one  coil  of  intestine  dips  down  below  it,  or  that  a  very  large 
portion  of  intestine  on  one  side  is  altogether  below  the  level  of  the  dull  part  on 
the  other;  on  the  other  hand,  it  may  prove  that  the  whole  surface  is  resonant,  or 
thai  dulness  is  very  limited  and  local. 

The  e\iilence*of  fluctuation  is  much  more  liable  to  be  indistinct  when  the  fluid 
is  contained  within  some  cyst,  than  when  it  is  free  in  the  peritoneum.  Fallacy  is 
best  avoided  by  producing  the  effect  in  various  ways;  tapping  gently,  giving  a 
short  sharp  stroke,  or  rubbing  the  finger  rapidly  along;  fluctuation  will  result  in 
each  case  if.  fluid  be  present.  In  addition  to  the  evidence  it  gives  of  the  actual 
presence  of  fluid,  we  learn  from  fluctuation  its  amount  and  distribution,  by  com- 
paring the  effect  at  different  distances,  and  observing  their  relation  to  what  we 
have'  already  ascertained  of  the  position  of  the  bowel  by  percussion.  In  very  many 
instances,  the  remarkable  distinctness  of  fluctuation  when  the  hands  of  the  ob- 
server are  placed  near  to  each  other,  and  its  entire  absence  at  a  greater  distance, 
afford  conclusive  evidence  of  the  limitation  of  the  space  in  which  it  is  contained; 
or,  on  the  other  hand,  its  indistinctness  when  the  hand  is  placed  over  the  surface 
of  tympanitic  bowels,  and  its  precision  when  the  hand  is  passed  beyond  them  to 
the' lumbar  region,  prove  with  equal  clearness  that  it  is  free  in  the  abdomen. 
But  the  examination  is  not  complete  till  we  have  observed  the  effect  of  change  of 
posture.  Immediately  on  any  change,  fluid  which  is  unlimited  by  membrane  gra- 
vitates to  that  which  is  now  the  lower  part  of  the  cavity,  and  all  the  relations  of 
percussion' and  fluctuation  are  more  or  less  altered.  This  cannot  occur  to  the 
same  extent  when  the  fluid  is  encysted;  but  it  is  to  be  remembered  that  it  is  spe- 
cifically heavier  than  intestine,  and,  though  more  slowly,  it  will  still  obey  the  laws 
of  gravitation,  as  far  as  its  mobility  will  permit. 

The  cases  in  which  diagnosis  is  most  difficult  are,  (")  when  a  unilocular  cyst  in 
a  female  has  come  to  occupy  the  whole  of  the  abdomen,  (6)  when  fluid  contained 
in  the  peritoneum  is  limited  by  adhesions. 

a.  The  history  shows,  perhaps,  that  the  disease  began  on  one  side,  and  the  pa- 
tient's health  is  not  seriously  affected,  except  so  far  as  inconvenience  and  derange- 
ment are  caused  by  pressure.  For  further  particulars  on  this  subject  the  reader 
is  referred  to  the  chapter  on  diseases  of  the  ovaries.  The  physical  examination 
has  reference  to  two  great  considerations;  first,  that,  in  the  necessary  displacement 
of  the  viscera,  they  are  pushed  to  one  side  by  a  cyst  which  has  grown  up  among 
them,  either  in  the  iliac  region  or  in  the  hypogastrium,  while  they  are  forced 
directly  upwards  by  fluid,  which  has  been  always  free,  and  has,  therefore,  neces- 
sarily accumulated  in  the  most  depending  part  of  the  peritoneum.  The  second 
consideration  is,  that  fluid,  having  always  this  tendency  to  gravitate  among  the 
intestines,  will  naturally,  in  change  of  posture,  flow  to  that  part  of  the  cavity  which 
is  made  to  assume  the  lowest  level,  except  it  be  restrained  by  the  cyst  membrane 
which  surrounds  it;  and,  connected  with  this,  that  the  intestines,  being  fastened 
to  the  body  by  long  loose  folds  of  peritoneum,  float  at  the  surface  of  a  fluid  wdiich 
immediately  surrounds  them,  but  cannot  so  float  if  the  fluid  be  separated  from 
them  by  being  contained  in  a  distinct  bag;  although  it  be  true  that  the  fluid^is 
heavier  than  they,  and,  if  the  cyst  have  room  to  change  its  place,  it  will  tend  to 
occupy  the  lowest  position. 

If  these  principles  are  steadily  kept  in  view,  the  details  of  their  application  will 
readily  occur  to  the  mind.  Thus  we  map  out  by  percussion  the  relative  positions 
of  the  fluid  and  the  more  resonant  contents,  and  observe  whether  the  line  of  dul- 
ness passes  horizontally  or  in  a  curve,  when  the  patient  is  in  an  erect  or  semi-erect 
position.  We  make  her  change  her  posture  and  again  observe  the  course  of  the 
resonance,  whether  it  dips  down  below  the  fluid  at  any  part.     We  place  her  hori- 


DROPSIES.  91 

zontally  on  her  back,  and  mark  whether  resonance  about  the  umbilicus  appears, 
and  move  her  from  side  to  side,  in  order  to  observe  whether  there  be  any  indica- 
tion of  the  intestine  floating  in  the  fluid.  Such  experiments,  conducted  with  a 
right  understanding  of  what  we  want  to  prove,  will  generally  leave  no  doubt  as  to 
the  nature  of  the  case. 

b.  It  now  and  then  happens  that,  when  ascites  exist,  old  adhesions  of  the  intes- 
tines are  found  binding  them  down  in  certain  positions ;  nay,  more,  almost  the 
whole  of  the  bowels  may  be  fixed  in  their  places,  and  the  fluid  poured  out  into  one 
portion  only  of  the  cavity,  where  it  is  retained  even  more  firmly  than  when  con- 
tained in  a  cyst.  In  considering  such  cases,  information  sufficient  to  put  us  on 
our  guard  against  mistake  may  be  derived  from  the  early  history  of  the  case  and 
the  condition  of  the  patient,  with  reference  to  the  date  of  formation  and  the  actual 
size  of  the  supposed  cyst.  The  pain  of  peritonitis,  such  as  must  have  existed  to 
cause  the  adhesions,  and  the  whole  character  of  the  seizure  can  never  be  simu- 
lated by  the  pain  occasionally  attending  the  first  appearance  of  ovarian  dropsy. 
Neither  does  the  same  disturbance  of  the  general  health  manifest  itself  when  an 
ovarian  cyst  has  become  filled  to  the  same  extent  for  the  firsttime,  as  must  of 
necessity  accompany  ascites  with  adhesions  so  extensive.  A  mistake  is  most  lia- 
ble to  be  made  when  the  patient  asserts  that  swelling  existed  before  the  occurrence 
of  pain,  and  other  causes  have  led  to  derangement  of  health. 

Hydatid  cysts  are  much  less  liable  to  be  mistaken  for  ascites.  They  are  discri- 
minated by  the  history  and  mode  of  growth,  their  firm  feeling  and  less  distinct 
fluctuation,  and  often  by  their  irregularity  of  outline ;  but,  more  than  this,  are  they 
distinguished  by  the  position  of  the  fluid  with  reference  to  the  intestine,  as  ascer- 
tained by  percussion,  not  obeying  the  laws  of  gravitation. 

Hydro-metra  is  only  liable  to  be  confounded  with  the  earlier  stages  of  ovarian 
dropsy.  A  distended  bladder  cannot  lead  to  any  mistake,  except  by  neglect  of 
one  of  the  essential  inquiries — the  condition  of  the  urine,  and  extreme  careless- 
ness in  investigating  the  case. 

Diagnosis  is  necessarily  incomplete,  except  we  can  ascertain 
•with  more  or  less  confidence  the  cause  upon  which  ascites  depends. 
This  is  most  apt  to  be  overlooked  when  anasarca  exists  to  such  an 
extent,  and  its  causes  appear  to  be  so  definite,  that  the  ascites  is 
considered  as  only  one  manifestation  of  general  dropsy.  Unques- 
tionably its  most  common  cause  is  obstruction  of  the  portal  circula- 
tion in  disease  of  the  liver,  causing  effusion  of  serum  from  the 
capillaries  of  the  various  venous  branches  which  unite  to  form  the 
vena  portre.  When  this  is  produced  by  chronic  inflammation  and 
shrinking  of  the  liver,  inflammatory  thickening  of  the  peritoneum 
often  goes  along  with.it,  and  probably  aids  the  effect  by  interfering 
with  absorption.  It  is  also  believed  that  chronic  peritonitis  may 
thus,  without  influencing  the  portal  circulation,  lead  to  accumulation 
of  fluid,  but  acute  peritonitis  is  never  in  the  first  instance  associated 
with  effusion.  In  the  recognition  of  these  two  causes  we  are  greatly 
aided  by  the  history  of  the  case ;  the  symptoms  which  may  more  or 
less  directly  point  to  either  will  be  reviewed  in  discussing  the  dis- 
eases of  the  liver  and  peritoneum.  Occasionally  no  distinct  indi- 
cation is  afforded,  but  the  kidneys  refuse  to  act,  and  the  intestinal 
secretions,  though  goaded  on  by  drastic  purgatives,  are  insufficient 
to  pump  off  the  accumulated  fluid,  until  the  abdomen  is  tapped, 
and  then  there  is  no  further  difficulty  in  keeping  the  accumulation 
under  control.  In  the  diagnosis  of  such  cases  we  must  not  pretend 
to  refine  too  much. 


92  DISEASES    OF    UNCERTAIN    SEAT. 

In  a  small  number  of  cases  occlusion  of  a  vein  produces  ascites, 
just  as  it  produces  local  oedema.  "Where  the  obstruction  occurs  be- 
fore the  intestinal  veins  reach  the  liver,  the  fluid  will  be  limited  to 
the  peritoneum ;  when  it  affects  the  inferior  cava,  anasarca  of  the 
lower  limbs  is  also  present.  All  of  these  are  exceptional ;  but  when 
the  cava  is  obstructed,  evidence  of  an  attempt  at  collateral  circu- 
lation over  the  surface  of  the  abdomen  will  give  a  clue  to  the  true 
explanation. 

A  genuine  case  of  tympanites,  when  from  distention  with  gas, 
the  abdomen  is  everywhere  excessively  resonant,  cannot  be  mistaken 
for  one  of  ascites;  but  let  us  avoid  the  opposite  error  of  overlook- 
ing the  presence  of  fluid  when  much  tympanitic  distention  exists. 
A  very  small  amount  of  fluid,  sinking  low  in  the  cavity  of  the  ab- 
domen, may  readily  escape  observation,  and  yet  it  may  be  of  much 
importance,  as  leading  us  to  seek  out  the  concurrent  disease  in  the 
liver  or  peritoneum. 

Division  II. — Hemorrhages. 

The  diseases  included  in  this  division  are  in  great  measure  inde- 
pendent of  the  lesion  in  virtue  of  which  the  blood  is  poured  out. 
They  are  only  met  with  casually  during  its  existence;  each  of  them 
is  found  in  association  with  a  considerable  variety  of  causes ;  and 
they  form  well-marked  subdivisions,  according  to  the  organs  from 
which  the  hemorrhage  occurs. 

The  distinctive  character  by  which  they  are  recognised  is  essen- 
tially an  objective  phenomenon ; — blood  is  poured  out,  and  is  to  be 
known  by  its  sensible  qualities.  Those  forms  of  disease  are  no 
less  genuine  hemorrhages  in  which  blood  is  poured  into  an  internal 
cavity;  but,  fortunately,  they  are  not  of  common  occurrence,  and 
must  be  regarded  merely  as  the  effect  of  internal  injury,  just  as  the 
bleeding  of  a  wound  is  the  effect  of  laceration.  The  cases  which 
we  have  to  consider  as  belonging  to  the  class  of  hemorrhages  occur 
cither  as  the  result  of  a  general  condition  of  system,  or  as  the  effect 
of  local  disease ;  this  distinction  is  more  evident  in  some  members 
of  the  class  than  in  others. 

§  1.  Epistaxis. — In  young  persons,  bleeding  from  the  nose  is  no 
necessary  indication  of  disease:  slight  exertion,  wringing  of  the 
nose,  or  a  blow  in  the  face  readily  excites  it  in  those  predisposed  to 
its  occurrence:  it  seems,  indeed,  to  act  as  a  sort  of  outlet  by  which 
injury  to  the  brain  from  an  excessive  supply  of  blood — "plethora," 
is  obviated.  It  may  become  a  habit,  and  under  such  circumstances 
be  excessive,  or  more  than  the  necessities  of  the  system  require. 
In  adults,  a  general  condition  of  plethora  demands  more  attention  ; 
when  it  is  merely  local,  and  cephalic  congestion  is  associated  with 
epistaxis,  it  is  frequently  dependent  on  disease  of  the  heart. 

Epistaxis  is  sometimes  the  form  of  bleeding  which  indicates  the 
existence    of  the    hemorrhagic  diathesis.     In   this  condition,  the 


HEMORRHAGES.  93 

bleeding  from  a  slight  wound  is  stopped  with  difficulty,  and  hemor- 
rhages from  various  organs  are  met  with  when  there  is  no  other  evi- 
dence of  disease.  It  also  accompanies  poverty  of  blood,  with 
wasting  of  the  albuminous  principle  and  coloured  corpuscles,  in 
antenna,  and  especially  in  albuminuria.  In  such  cases,  a  condition 
of  simple  hypertrophy  of  the  heart,  so  often  associated  with  disease 
of  the  kidney,  may  possibly  have  something  to  do  with  its  occur- 
rence ;  but  this  is  certainly  not  its  constant  cause.  As  a  conse- 
quence of  local  disease,  it  most  commonly  arises  from  polypoid  or 
fungoid  growths  in  the  nose. 

§  2.  Haemoptysis. — Literally,  spitting  of  blood;  the  term  is  now 
restricted  to  hemorrhage  from  the  lungs.  The  appearance  of  blood 
in  the  sputa  from  any  other  source  may  be  called  spurious,  that 
from  the  lungs  genuine  haemoptysis. 

a*  Spurious :  a  very  frequent  occurrence  in  hysterical  females ; 
or  a  consequence  of  a  relaxed  or  aphthous  state  of  the  tonsils,  or 
sponginess  of  the  gums :  it  is  derived  in  both  cases  from  the  mouth 
or  fauces.  In  the  latter  their  altered  condition  will  be  seen  on 
inspection ;  in  the  former  the  general  state  of  health,  and  the  pre- 
sence of  hysterical  symptoms,  will  serve  to  confirm  the  opinion  we 
are  led  to  form  from  an  examination  of  the  sputa.  The  blood, 
which  appears  as  streaks  or  small  clots,  is  mixed  with  brownish  and 
sometimes  fetid  saliva,  which  has  a  glairy  appearance,  is  free  from 
froth,  and  is  only  partially  intermixed  with  bronchial  mucus;  the 
secretion  from  the  lungs  floats  upon  the  saliva,  is  untinged  with 
blood,  and  does  not  differ  from  that  which  is  occasionally  expecto- 
rated by  all  persons  in  health. 

b.  Genuine  haemoptysis  occurs  in  very  varying  quantity,  from  a 
slight  streak  in  the  frothy  mucus  secreted  by  irritated  air-tubes, 
such  as  is  met  with  in  early  phthisis  or  bronchitis,  to  an  incredible 
amount  of  pure  unmixed  blood.  In  the  former  there  is  little  diffi- 
culty in  making  out  that  its  source  is  pulmonic,  when  we  have  the 
evidence  of  existing  cough,  accompanied  by  expectoration  clearly 
coming  from  the  lungs,  with  which  blood  of  a  florid  colour  is  evi- 
dently intermixed:  but  when  the  quantity  is  larger,  it  is  sometimes 
not  easy  to  say  whether  the  blood  come  from  the  trachea  or  from 
the  oesophagus — whether  the  case  be  one  of  haemoptysis  or  haerua- 
temesis.  We  are  guided  in  great  measure  by  the  history  of  the 
precursory  symptoms,  and  especially  by  the  existence  of  cough; 
this  one  fact,  indeed,  is  often  conclusive.  Pain,  if  it  exist,  is  re- 
ferred to  the  middle  of  the  sternum,  or  said  to  extend  right  across 
the  thorax  in  haemoptysis ;  it  is  referred  to  the  epigastrium  in  hae- 
matemesis.  In  haemoptysis  there  is  first  a  sensation  of  tickling 
in  the  throat,  and  then  the  blood  comes  up  with  a  hawking  or  a 
true  cough:  in  haematemesis  the  first  sensation  is  of  sickness,  and 
an  effort  of  retching  is  accompanied  by  a  free  discharge  of  blood, 
or  of   blood  and  glairy  mucus:    subsequently,  if  a  considerable 


9-i  DISEASES    OF    UNCERTAIN    SEAT. 

quantity  continue  to  be  brought  up,  it  seems  to  be  accompanied 
by  retching  in  both  cases,  and  then,  the  diagnosis  may  be  more 

obscure. 

If  the  patient  be  seen  during  its  continuance,  there  is  little 
chance  of  mistaking  the  two.  If  he  have  not  been  seen  till  after- 
wards, the  persistence  of  cough,  with  a  few  blood-stained  sputa  or 
clots  of  blood  surrounded  by  frothy  mucus,  decides  in  favour  of 
haemoptysis:  the  appearance  of  black  altered  blood  in  the  stools 
proves  it  to  have  been  hamiateinesis,  especially  if  hemorrhage  by 
the  mouth  have  entirely  and  at  once  ceased;  it  can  only  get 
into  the  stools  by  being  swallowed,  when  it  comes  from  the  lungs. 
]>oth  conditions  may  be  simulated  by  blood  from  the  back  of  the 
nares  trickling  down  into  the  oesophagus  or  the  trachea ;  but  here 
cpistaxis  indicates  its  source. 

Hemorrhage  from  the  lungs  is  associated  with  four  different  con- 
ditions of  disease :  (a)  phthisis,  and  more  rarely  bronchitis ;  (b)  dis- 
ease of  the  heart,  especially  with  mitral  regurgitation  ;  (c)  aneurism  ; 
(d)  intra-thoracic  fungoid  growths. 

a.  In  phthisis  the  quantity  is  very  variable.  It  may  be  little  more  than  a  few 
streaks  mixed  with  the  purely  bronchial  expectoration  of  early  phthisis,  or  with 
the  muco-purulent  fluid  of  its  more  advanced  stages.  This  slight  streaking,  al- 
ways an  important  symptom,  is  of  more  weight  when  appearing  in  a  chronic  af- 
fection of  the  lungs  than  when  the  expectoration  consists  of  simple  mucus.  It 
may  be  impossible  to  assert  positively  in  any  given  case  that  the  lungsare  entirely 
free  from  tubercles;  yet  where  no  trace  of  their  existence  is  detected,  it  would  ap- 
pear that  the  strain  of  a  laboured  cough  with  scanty  expectoration,  especially  if 
emphysema  be  present,  and  the  mucous  membrane  congested,  occasionally  gives 
rise  to  a  very  slight  amount  of  genuine  haemoptysis;  and  in  such  circumstances 
experience  teaches  that  we  may  be  justified  in  taking  a  more  favourable  view  of 
the  case.  A  cough  of  longer  standing,  with  any  opacity  of  the  sputa,  makes  the 
appearance  of  blood  to  the  very  smallest  amount  a  serious  and  alarming  symptom. 

It  may  be  in  very  considerable  quantity,  while  yet  the  disease  has  made  com- 
paratively little  progress.  In  these  circumstances  it  causes  obstruction  to  the 
passage  of  air  through  the  tubes,  and  its  particular  locality  may  be  traced  by  the 
sounds  heard  with  the  stethoscope  at  or  near  the  apices  of  the  lungs.  In  some 
rare  instances,  when  it  is  very  abundant,  coming,  perhaps,  with  a  sudden  gush,  it 
proceeds  from  the  erosion  of  a  vessel  in  a  vomica  or  abscess:  the  other  signs  of 
phthisis  are  then  well  marked. 

The  blood  is  at  first  always  florid,  and,  except  when  in  very  great  quantity,  also 
frothy;  it  becomes  scanty  and  brown,  or  blackish,  as  the  attack  is _ passing  off, 
when  no  more  is  poured  out  aud  that  which  remains  in  the  tubes  is  gradually 
being  got  rid  of  by  expectoration. 

b.  In  disease  of  the  heart  the  amount  is  seldom  or  never  great,  and  it  is  more 
variable  in  appearance,  partly  florid  and  frothy,  partly  mixed  with  darker  clots, 
which  generally  indicate  the  existence  of  what  is  called  apoplexyof  the  lungs. 
The  blood  is  mixed  with  mucus  or  muco-pus,  according  to  the  previous  condition 
of  the  patient,  as  suffering  more  or  less  from  bronchial  irritation.  Dyspnoea  is 
its  invariable  precursor,  from  the  retardation  of  the  passage  of  the  blood  through 
the  lungs;  and  this  very  frequently  gives  rise  to  oedema  of  the  lung,  broncborrhcea, 
or  bronchitis.  The  essential  condition  is  one  of  obstruction  to  the  onward  current, 
as  the  blood  ente^  or  leaves  the  left  ventricle  of  the  heart;  and  the  effect  becomes 
most  marked  when  this  obstruction  is  caused  by  a  backward  flow  of  blood  through 
the  mitral  orifice,  in  consequence  of  which  a  double  supply  of  blood  is  thrown 
upon  the  pulmonic  veins.  The  examination  of  the  heart  ought  to  leave  no  doubt 
as  to  this  cause  of  hemorrhage,  and  sometimes  auscultation  and  percussion  indi- 
cate with  great  precision  its  exact  seat. 


HEMORRHAGES.  95 

c.  In  aneurism  the  gush  of  blood  is  generally  great,  sometimes  terrific,  followed 
by  almost  instantaneous  death.  This  is  what  we  should  expect  from  the  very  na- 
ture of  the  disease;  because,  though  partial  hemorrhage  may  occurfrom  erosion 
of  lung  tissue  by  pressure,  or  from  partial  obstruction  of  vessels,  in  by  far  the 
greater  number  the  blood  comes  from  actual  bursting  of  the  sac.  The  indications 
by  which  aneurism  may  be  discovered  will  be  afterwards  considered.  (See  Dis- 
eases of  Blood-vessels.) 

d.  In  fungoid  growths  the  blood  is  never  brought  up  in  any  quantity.  It  has 
sometimes  very  much  the  same  appearance  as  that  caused  by  disease  of  the  heart, 
and  then  it  would  appear  to  be  the  result  of  pressure  and  obstruction;  more  fre- 
quently it  is  seen  as  small  clots,  or  as  a  sanious  discharge,  or  it  has  the  appearance 
of  currant  jellv.  The  diagnosis  of  intra-thoracic  tumour  will  be  afterwards  dis- 
cussed, as  one  of  the  forms  of  disease  of  the  chest. 

In  addition  to  these,  the  more  ordinary  associations  of  haemoptysis,  it  must  be 
remembered  that  the  sputa  of  pneumonia  are  really  tinged  with  blood,  which, 
though  in  the  later  stages  it  acquire  a  brown  or  rusty  colour,  may  be  in  the  first 
onset  of  a  severe  attack,  quite  florid  in  appearance.  Conditions  of  congestion  from 
gravitation,  in  fevers  and  blood  diseases  generally,  may  be  accompanied  by  an 
oozing  which  gives  the  expectoration  more  or  less  of  the  same  character.  Bleed- 
ing-from  the  lungs  may  also  go  along  with  other  hemorrhages  in  cases  of  purpura 
hemorrhagica;  but  such  conditions,  although  they  may  rank  haemoptysis  as  one 
of  their  symptoms,  cannot  be  classed  under  that  head. 

Vicarious  hemorrhage,  in  suppression  of  the  habitual  flow  from  the  uterus,  or 
of  that  from  the  hemorrhoidal  vessels,  is  alleged  sometimes  to  put  on  the  charac- 
ters of  haemoptysis.  Among  females  such  a  condition  usually  belongs  to  the  spu- 
rious form;  the  blood  comes  from  the  mouth  and  fauces,  and  not  from  the  lungs 
at  all.  It  is  very  often  entirely  hysterical;  an  excited  fancy  finding  something  in 
the  teeth,  the  gums,  or  the  throat  to  work  upon,  and  the  blood  being  really  pro- 
duced by  suction.  Strange  to  say,  this  incident  very  often  occurs,  without  any 
intention  of  deception,  at  or  about  the  time  when  the  catamenia  should  have  ap- 
peared; probably  from  a  notion  being  very  widely  spread  among  mothers  and 
nurses  that  the  blood  is  liable  to  "come  some  other  way"  in  amenorrhcea. 

Well  authenticated  cases  of  hemorrhage  from  the  lungs  for  the  relief  of  plethora, 
an  event  so  common  in  the  mucous  membrane  of  the  nose  and  the  rectum,  are 
very  rare  indeed.  Perhaps  scarcely  one  is  on  record  which  is  unexceptionable ; 
at  all  events,  the  probability  is  very  greatly  against  genuine  haemoptysis  depend- 
ing on  such  a  cause. 

§  3.  Hsematemesis. — It  is  unnecessary  again  to  go  over  the  points 
which  serve  to  distinguish  between  hemorrhage  from  the  stomach, 
and  hemorrhage  from  the  lungs.  The  history  must  be  our  guide ; 
and  not  whether  the  patient  say  he  brought  it  up  from  his  chest  or 
his  stomach;  a  statement  which,  from  the  confused  ideas  generally 
entertained  of  the  relation  of  internal  organs,  is  quite  valueless :  the 
question  is,  whether  he  felt  sick  or  faint  before  he  brought  it  up,  or 
whether  he  had  a  cough.  This  faintness  is  often  well  marked,  in 
consequence  of  a  large  quantity  of  blood  being  poured  out  into  the 
stomach  before  its  action  is  inverted  so  as  to  produce  vomiting ;  but 
this  is  by  no  means  constant. 

In  quantity  the  blood  is  sometimes  very  considerable  ;  in  consist- 
ence clotted,  or  grumous,  and  mixed  with  the  contents  of  the  sto- 
mach ;  in  colour  it  is  almost  always  dark :  occasionally  the  clots  are 
partially  decolorized,  indicating  that  the  blood  has  lain  some  time 
in  the  stomach.  The  formation  of  a  true  clot  leads  rather  to  the 
suspicion  that  a  vessel  is  ruptured  ;  but  in  any  form  of  hemorrhage, 
where  the  quantity  of  blood  poured  out  is  great,  it  is  more  or  less 


9G  DISEASES    OF    UNCERTAIN    SEAT. 

clotted.  The  action  of  the  acid  in  the  stomach  has  the  effect  of 
blackening  the  colouring  matter;  but  occasionally  the  discharge  of 
blood  goes  on  for  so  long  that  the  stomach  becomes  entirely  emptied 
of  its  natural  secretion,  and  then  the  latter  efforts  of  vomiting 
bring  up  pure  florid  blood.  This  condition  is  that  which  is  simulated 
by  prolonged  and  profuse  hemoptysis  when  retching  accompanies 
its  advanced  stage. 

The  blood  in  hrcmatemesis  is  derived  from  three  sources :  (a) 
from  erosion  of  a  vessel;  (b)  by  exudation  from  the  surface  of 
healthy  mucous  membrane;  (c)  by  oozing  from  a  diseased  portion 
of  the  stomach  in  cancerous  formations. 

a.  Erosion  is  found  either  as  the  result  of  ulceration  of  the  mucous  membrane, 
or  as  the  fatal  termination  of  an  aneurism  when  the  vessel  has  burst  into  the  sto- 
mach. Both  forms  of  hemorrhage  are  severe,  and  very  often  fatal.  Ulceration 
of  the  stomach,  however,  is  generally  preceded  by  symptoms  of  dyspepsia  and  a 
burning  sensation  after  eating:  it  is  more  common  in  young  females  than  in^males 
or  persons  of  advanced  age.  The  evidence  of  the  existence  of  aneurism  is  less 
direct.     (See  Chap.  IX.,  Div.  ii.,  §  2,  Tumours.) 

b.  Blood  may  exude  from  the  surface  of  the  mucous  membrane  under  a  variety 
of  circumstances;  and  this  is  especially  associated  with  disease  of  the  liver  and 
spleen.  In  quantity  often  great,  the  exudation  may  go  on  for  a  considerable  pe- 
riod, so  that  the  stomach  may  be  emptied  three  or  four  times  in  succession;  the 
intervals  are  usually  long,  so  that  the  colour  continues  dark  throughout.  _  The  age 
and  habits  of  the  patient  are  to  be  considered,  as  well  as  the  evidence  derived  from 
other  sources  indicating  hepatic  or  splenic  disease.  Hemorrhage  from  such  causes 
very  seldom  occurs  in  early  life,  and  persons  of  dissipated  habits  are  more  liable 
to  it  than  others.  Hsemateraesis  is  sometimes  vicarious  of  menstruation:  this  is 
by  far  the  most  common  and  the  best  established  of  the  instances  of  hemorrhage 
recurring  at  pretty  regular  intervals  in  cases  of  amenorrhcea;  hence  jt  is  always 
important,  when  hiematemesis  is  present  in  a  young  female,  to  make  inquiry  into 
the  state  of  the  uterine  functions. 

It  is  not  uncommon  as  one  of  the  forms  of  hemorrhage  in  purpura  and  scurvy; 
it  occurs  as  black  vomit  in  yellow  fever;  it  sometimes  follows  the  ingestion  of 
some  irritant  poison.  All  of  these  are  purely  symptomatic,  and  their  diagnosis  is 
based,  not  on  the  mere  existence  of  hamiateniesis,  which  is  casual,  but  upon  the 
other  symptoms  of  each  form  of  disease. 

c.  A  certain  admixture  of  blood  with  the  contents  of  the  stomach  in  persistent 
vomiting  is  an  early  and  only  too  certain  indication  of  commencing  scirrhus; 
after  ceasing  for  a  time,  it  is  very  apt  to  reappear  as  ulceration  proceeds.  Its 
distinctive  characters  are  a  grumous  and  scarcely  clotted  appearance,  much  re- 
sembling "  coffee  grounds,"  and  its  small  amount  on  each  occasion,  even  when 
ulceration  has  proceeded  to  its  greatest  extent.  This  is  to  be  explained  by  the 
circumstance  that  previous  disorganization  has  generally  rendered  the  vessels  im- 
pervious before  they  are  perforated  by  the  ulcerative  process. 

§  4.  Hsematuria  is  the  name  given  to  any  escape  of  blood  with 
the  urine.  The  presence  of  blood  must  not  be  assumed  from  its 
colour:  some  vegetable  colouring  matters  give  to  the  urine  a  pink 
or  bright  red  hue;  in  some  disorders,  deposits  of  a  red  colour 
closely  resemble  it ;  and  an  admixture  of  bile  produces  an  appear- 
ance very  similar  to  that  caused  by  dark  and  altered  blood.  The 
details  of  this  subject  will  be  given  afterwards  (see  Chap.  XXX., 
§  3;)  but,  as  a  ready  test,  it  will  be  observed  that,  when  blood  _ is 
present,  the  urine  is  not  only  changed  in  colour,  but  has  lost  its 


HEMORRHAGES.  97 

natural  transparency,  and  this  opacity  is  increased  by  heat  and  ni- 
tric acid.  When  the  microscope  can  be  employed,  blood-globules 
will  be  seen,  and  give  certainty  to  the  diagnosis.  In  females  it  is 
further  necessary  to  ascertain  that  the  blood  does  not  come  from 
the  uterus  or  vagina  at  the  time  of  micturition. 

Its  source  may  be  in  any  part  of  the  urinary  apparatus,  from  the 
minute  tubes  of  the  kidney  to  the  extremity  of  the  urethra:  in 
quantity  and  colour  it  varies  very  much.  When  the  amount  is 
considerable  and  the  colour  florid,  it  probably  proceeds  from  some 
abrasion  of  surface,  caused  either  (a)  by  the  presence  of  a  calculus, 
or  (b)  by  ulceration  or  other  injury,  or  it  is  the  result  of  fungoid 
growth;  (<?)  similar  discharges  occur  in  purpura  and  the  hemor- 
rhagic diathesis:  (d)  when  in  smaller  amount,  and  of  a  pink,  brown, 
or  smoke  colour,  it  is  generally  a  symptom  of  chronic  disease  of 
the  kidney. 

a.  Calculus. — Generally  occurring  in  middle  life,  or  in  advanced  age,  the  con- 
cretion may  have  lain  quiescent  in  the  kidney  for  a  long  period,  until  some  sudden 
shock  or  movement  causes  its  displacement,  when  its  sharp  edges  wound  the  de- 
licate membrane  of  the  infundibulurn,  and  give  rise  to  a  pretty  copious  how  of 
blood.  This  varies  remarkably  from  day  to  day,  till  at  length  the  membrane  be- 
comes adapted  to  the  new  position  of  the  stone,  or  it  passes  out  of  the  body.  The 
blood  has  a  tendency  to  coagulate,  and  small  clots  are  seen  at  different  times  in 
the  urine;  they  are  sometimes  partially  decolorized,  having  the  shape  of  the  ure- 
ter, and  appearing  like  small  white  worms.  The  passage  of  the  stone  along  the 
ureter  is  generally  attended  by  symptoms  very  analogous  to  those  indicating  its  pre- 
sence in  the  kidney.  Pain  is  always  present;  it  is  situated  in  the  region  of  the 
kidney,  confined  to  one  side,  extending  along  the  course  of  the  ureter,  and  shoot- 
ing down  the  groin  and  the  thigh,  with  retraction  of  the  testicle.  The  circum- 
stances connected  with  this  event  will  have  to  be  more  fully  discussed  when  we 
speak  of  diseases  of  the  kidney,  under  the  head  of  Nephralgia  and  Nephritis. 

When  the  calculus  is  situated  in  the  bladder,  or  has  passed  into  the  urethra, 
before  it  can  become  the  cause  of  hemorrhage,  there  will  be  other  symptoms  of  its 
presence;  mucous  or  purulent  secretion,  sudden  stoppage  in  the  urine,  and  pain 
referred  to  the  glans  penis,  &c. 

b.  In  disease  of  the  bladder  the  largest  amount  of  pure  blood  is  passed,  not  un- 
frequently  almost  unmixed  with  urine,  coagulating  into  a  solid  mass  in  the  uten- 
sil, or  even  entirely  filling  the  bladder  with  a  firm  clot.  The  disease  is  generally 
of  a  fungoid  nature,  but  occasionally  a  similar  amount  of  hemorrhage  is  produced 
by  chronic  ulceration;  in  the  latter,  the  previous  history  ought  to  indicate  its  na- 
ture; in  the  former,  the  introduction  of  the  catheter  is  attended  with  deep-seated 
pain  and  a  flow  of  blood  from  the  fungous  surface.  Fungoid  disease  of  the  kid- 
ney is  also  sometimes  attended  with  pretty  copious  discharge  of  blood,  but  there 
is  little  to  point  out  its  true  nature. 

Hemorrhage  from  the  bladder  may  be  also  caused  by  the  injudicious  introduc- 
tion of  the  sound,  or  catheter.  Prostatic  hemorrhage  is  rare;  disease  of  this  gland 
is  chiefly  indicated  by  constant  difficulty  in  emptying  the  bladder,  and  its  condition 
must  be  ascertained  by  examination  per  rectum;  in  hemorrhage  from  the  urethra 
the  blood  is  not  passed  at  the  time  of  micturition,  but  flows  without  any  attempt 
to  empty  the  bladder.     Both  these  affections  are  regarded  as  surgical. 

c.  As  an  accompaniment  of  purpura,  blood,  when  present  in  the  urine,  is  gene- 
rally of  considerable  amount  and  bright  colour;  the  diagnosis  rests  on  the  other 
signs  of  the  altered  condition  of  the  blood  which  it  exhibits.  Hematuria  is  com- 
paratively very  rare  as  an  idiopathic  disease:  it  is  important  to  inquire  into  the 
previous  existence  of  other  hemorrhages,  of  which  it  may  be  vicarious;  such,  for 
example,  as  piles,  or  of  epistaxis  and  copious  bleeding  from  slight  wounds,  which 
may  be  taken  as'evidence  of  the  hemorrhagic  diathesis. 

7 


08  'diseases  of  uncertain  seat. 

(1.  In  chronic  d  of  the  kidney  the  urine  is  often  tinged  of  a  smoky  colour 

1  >y  the  intermixture  of  a  small  quantity  of  blood,  which  has  been  altered  in  ap- 

fiearance  by  the  action  of  the  acid  present  in  the  urine.  When  the  urine  is  alka- 
ine,  th(  colour  has  a  pinkish  hue;  it  has  seldom  the  florid  look  of  unaltered  blood. 
Exactly  the  same  appearances  are  often  found  in  the  urine  passed  after  an  attack 
of  scarlatina  when  dropsy  occurs. 

In  both  cases  the  distinguishing  feature  of  the  disease  with  which  this  form  of 
hemorrhage  is  associated  is  that  there  is  a  much  larger  amount  of  albumen  pre- 
sent in  the  urine,  as  proved  by  chemical  re-agents,  than  could  have  been  derived 
fnun  simple  admixture  of  the  actual  quantity  of  blood  necessary  to  produce  the 
red  or  brown  colour. 

These  observations  all  tend  to  show  that  bsematuria  is  almost  constantly  a 
symptom,  though  a  casual  one,  of  disease  in  some  portion  of  the  urinary  appara- 
tus ;  and  all  the  points  which  have  been  alluded  to  require  further  study,  if  more 
than  a  mere  guess  at  its  cause  be  sought  for.  In  giving  it  a  place  among  the  he- 
morrhages, we  only  seek  to  point  out  its  accidental  and  uncertain  character,  and 
that  it  is  rather  to  be  regarded  in  many  instances  as  an  intercurrent  disorder, 
making  its  appearance  in  the  course  of  some  more  severe  malady. 

§  5.  Intestinal  Hemorrhage. — When  blood  is  passed  by  stool,  it 
is  necessary  to  determine  whether  there  be  hemorrhoids,  internal  or 
external.  In  their  absence,  we  must  proceed  to  inquire  into  the 
constitutional  and  precursory  symptoms.  Whether  it  have  been 
preceded  by  ha^matemesis,  by  fever,  by  diarrhoea,  or  by  dysentery, 
the  colour  of  the  blood  will  aid  in  determining  from  what  portion 
of  the  canal  it  comes.  The  darker  in  colour,  the  higher  up  is  its 
source;  the  brighter,  and  the  more  nearly  it  approaches  to  the  or- 
dinary colour  of  blood,  the  nearer  is  its  point  of  discharge  to  the 
anus;  black  and  pitchy  after  hasrnatemesis,  it  is  bright  and  florid  in 
dysentery. 

When  not  proceeding  from  the  stomach,  its  most  common  source 
is  ulceration  of  the  mucous  membrane  in  some  part  of  the  canal. 
It  is  not  unfrequently  present  in  purpura,  and  sometimes  appears 
to  depend  on  a  state  of  simple  debility  and  extreme  relaxation  of 
the  mucous  membrane;  but  when  such  cases  terminate  favourably, 
there  must  always  remain  a  doubt  whether  ulceration  did  not  exist. 

§  6.  Uterine  Hemorrhage  may  occur  in  perfect  health,  or  as  a 
consequence  of  disease:  the  mere  fact  of  the  continuance  or  fre- 
quent recurrence  of  hemorrhage  is  not  of  itself  any  sufficient  indi- 
cation of  disease  of  the  organ.  The  character  we  would  assign  to 
it,  as  distinguished  from  monorrhagia,  is  the  irregularity  of  the 
periods  of  its  occurrence ;  but  so  great  is  the  tendency  to  periodicity 
in  this  organ,  that  such  a  rule  is  liable  to  error.  Menorrhagia, 
properly  so  called,  consists  in  an  increased  flow  of  the  menstrual 
discharge,  the  actual  quantity  being  greater,  the  time  of  its  duration 
longer,  and  the  intervals  of  repose  shorter,  but  all  perfectly  regular 
in  their  recurrence,  and  gradually  developed.  Hemorrhage,  again, 
comes  on  suddenly,  and  is  quite  independent  of  the  menses ;  if  it 
happen  at  one  period,  it  does  not  follow  at  the  next,  but  may  again 
recur  at  some  future  one,  or  at  any  intermediate  time. 

a.  When  it  is  found  in  apparent  health,  it  is  generally  the  conse- 


HEMORRHAGES.  99 

quence  either  (1)  of  sudden  alarm,  especially  soon  after  the  usual 
menstrual  period,  or  (2)  of  abortion :  in  such  cases  it  may  continue 
at  intervals  for  weeks  or  months  afterwards,  from  want  of  care  and 
proper  management. 

b.  As  a  consequence  of  disease,  it  is  most  commonly  associated 
with  (1)  polypus  or  fibrous  tumours;  (2)  fungoid  growths  and  can- 
cer; (3)  sometimes  with  the  hemorrhagic  diathesis,  when  it  is  fol- 
lowed by  intense  anoemia,  and  may  even  prove  fatal.  The  local 
diseases  which  give  rise  to  hemorrhage  from  the  uterus  must  be 
ascertained  by  tactile  examination :  their  consideration  will  be  re- 
sumed at  a  later  part  of  our  inquiry.  (See  Chap.  XXXIII.,  Dis- 
eases of  the  Uterus.) 


100 


CHAPTER  VIII. 

THE    CHRONIC    BLOOD-AILMENTS. 

§  1,  Purpura  and  Scurvy — their  Discrimination — §  2,  Anaemia — 
Causes  and  Associations — §  3,  Chlorosis — §  4,  Ansemic  Blood- 
murmurs — §  5,  CacJuvmia,  or  Cachexia — Pysemia — Secondary 
Deposits. 

§  1.  Purpura  and  Scurvy. — These  two  diseases  have  this  feature 
in  common,  that  they  are  forms  of  subcutaneous  hemorrhage,  oc- 
curring spontaneously  without  pain  or  injury,  and  having  no  assign- 
able cause  other  than  a  peculiar  condition  of  the  blood.  Their 
phenomena  are  essentially  objective;  their  existence  being  deter- 
mined by  the  presence  of  dark-coloured  persistent  spots  or  patches 
of  varying  size,  having  the  appearance  of  purple  stains  or  livid 
bruises  of  the  skin. 

These  states  are  not  identical  with  what  has  been  already  denominated  the 
hemorrhagic  diathesis.  Spontaneous  hemorrhages  are  liable  to  occur  in  both 
conditions;  the  external  characters  differ  in  this  respect,  that  in  the  one  blood  is 
effused  under  the  skin  without  assignable  cause,  and  with  no  apparent  alteration 
of  texture,  while  in  the  other  it  is  only  poured  out  where  there  is  some  breach  of 
surface,  and  is  then  stanched  with  extreme  difficulty;  fatal  hemorrhage  has  in 
such  circumstances  followed  the  extraction  of  a  tooth.  It  is  probable  that  the 
spontaneous  internal  hemorrhages  in  each  case  follow  the  same  rule,  and  that 
there  is  really  some  abrasion  of  the  mucous  membrane,  or  rupture  of  a  small  ves- 
sel, in  the  one  and  not  in  the  other. 

They  differ  from  each  other, — (a)  in  scurvy  being  very  frequently 
accompanied  by  sponginess  of  the  gums,  which  is  never  the  case 
with  purpura,  but  this  indication  is  not  always  present;  (b)  in  the 
characters  of  the  spots  themselves.  In  purpura  they  are  generally 
small  and  of  a  very  dark  colour;  the  skin  seems  to  be  stained 
through  with  a  purple  dye :  when  larger  patches  exist,  they  seem  to 
be  composed  of  innumerable  smaller  ones  run  together,  some  of 
which  are  found  quite  distinct  in  the  immediate  neighbourhood,  or 
in  other  partg  of  the  body;  the  spots  are  soft  and  flaccid.  In 
scurvy  the  patches  are  generally  large,  and  always  more  or»less  hard ; 
their  colour  is  more  livid  than  purple,  resembling  bruises  rather 
than  stains  of  the  skin. 

Purpura  is  not  unfrequently  associated  with  hematuria,  or  intes- 
tinal hemorrhage ;  it  is  then  usually  called  purpura  hemorrhagica. 
It  is  liable  to  occur  in  any  circumstances  which  deteriorate  the 
quality  of  the  blood,  and  is  therefore  found  in  disease  of  the  kid- 
ney, liver,  spleen,  &c.  It  is  also  met  with  occasionally  in  conditions 
of  blood-poisoning,  such  as  pyemia  and  severe  small-pox :  it  forms 
the  true  petechia:  in  typhus  fever.     When  it  arises  spontaneously 


ANiEMIA.  101 

*  there  must  have  been  some  antecedent  cause  for  the  altered  condi- 
tion of  the  blood,  though  this  cannot  always  be  traced.  Scurvy, 
on  the  other  hand,  is  especially  associated  with  deficiency  of  some 
element  ordinarily  derived  from  the  vegetable  kingdom,  and  gene- 
rally believed  to  be  an  acid,  because  of  the  prophylactic  as  well  as 
curative  powers  of  lemon-juice:  it  was  much  more  common  than 
usual  at  the  first  outbreak  of  the  potato  disease,  when  the  poor  were 
deprived  of  this  their  ordinary  vegetable. 

§  2.  Anoemia. — In  the  classification  of  symptoms  which  afford 
indications  regarding  the  general  state  of  the  patient,  reference  was 
made  to  those  derived  from  the  aspect  and  colour  of  the  face.  None 
of  these  is  more  striking,  or  perhaps  more  valuable,  than  that  pre- 
sented by  anremia; — loss  of  that  natural  complexion  which  is  pro- 
duced in  health  by  the  fine  network  of  capillaries  spread  over  the 
skin,  especially  of  the  cheeks,  and  also  over  the  mucous  membrane 
bounding  the  lips  and  the  nose ;  by  inference  deficiency  of  blood, 
but  mo|p  particularly  of  the  red  colouring  matter.  This  condition 
depends  therefore  either  on  absolute  want  of  blood,  or  on  dispro- 
portion between  its  various  elements. 

Its  causes  are  very  various :  they  may  often  be  detected  in  the 
history  of  the  case.  The  exact  duration  of  the  disease  can  seldom 
be  ascertained,  except  when  loss  of  blood  has  been  occasioned  by 
hemorrhage,  because  its  commencement  is  generally  insidious. 
Patients  cannot  associate  their  pallor  with  those  conditions  out  of 
which  it  has  arisen;  but  more  commonly,  in  describing  the  com- 
mencement of  their  illness,  refer  to  those  secondary  states  which 
have  first  made  them  conscious  of  loss  of  health,  such  as  palpitation 
or  dyspnoea,  headache,  dyspepsia,  general  weakness,  and  among 
females  diminution  or  suppression  of  the  menstrual  discharge.  The 
history  ought,  if  possible,  to  go  beyond  these,  to  the  antecedent 
state  out  of  which  the  whole  category  of  symptoms  has  sprung,  and 
to  take  note  of  the  order  in  which  the  circumstances  of  which  the 
patient  is  cognizant  have  successively  appeared. 

The  inquiry  on  the  part  of  the  physician  embraces  the  following 
points: — a.  The  existence  of  hemorrhage,  b.  Want  of  proper  nu- 
triment, c.  Causes  which  prevent  the  nutriment  from  being  con- 
verted into  healthy  blood,  d.  Conditions  of  system  which  directly 
tend  to  deteriorate  the  blood. 

a.  Hemorrhage  first  diminishes  the  quantity  of  the  circulating  fluid  ;  and  when 
this  is  again  made  up  by  the  absorption  of  liquid,  its  quality  is  impoverished. 
The  hemorrhages  most  commonly  producing  this  effect  are  from  the  uterus  in  fe- 
males, and  from  the  bowels  in  both  sexes;  anaemia  frequently  follows  on  haema- 
teraesis,  and  more  rarely  on  prolonged  epistaxis;  it  is  also  to  be  seen  in  patients 
who  have  been  frequently  bled.  When  associated  with  haemoptysis  or  haematuria, 
it  is  rather  the  result  of  the  disease  of  the  lungs  or  kidney  than  of  the  loss  of  blood. 
It  must  not  be  forgotten  that  the  hemorrhage  may  be  the  consequence  and  not 
the  cause  of  the  changed  qualities  of  the  blood. 

b.  Simple  anaemia  is  generally  the  effect  of  insufficient  nutriment;  when  the 
food  is  improper  in  quality,  special  forms  of  disease  are  more  liable  to  be  engen- 


102  CHRONIC    BLOOD    AILMENTS. 

(I led,  cachexia,  purpura,  scurvy,  &c.     Starvation  implies  absolute  want  of  Wood, 
and  the  disproportion  of  the  constituents  is  only  referrible  to  excess  of  water. 

Fhe  caosea  which  prevent  the  formation  of  blood  include  especially  disorders 
igestire  apparatus,  the  stomach,  the  liver,  and  the  intestines;  as  well  as 
ion   to  the  absorbents,  as  seen  in  mesenteric  disease.     We  must  bear  in 
■  r,  that  derangements  of  all  possible  kinds  may  result  from  the  ana> 
mia  in  place  of  causing  it.     "We  may  be  somewhat  guided  in  forming  our  judg- 
ment by  the  history  of  the  case,  pointing  out  priority  of  occurrence  in  the  dyspep- 
vmptoms,  or  in  the  general  feeling  of  weakness,  and  by  the  relative  intensity 
ach  class  of  indications;  the  anaemia  is  much  more  intense  when  it  produces 
the  dyspepsia  than  when  caused  by  it.     There  can  be  but  little  difference  between 
the  want  of  blood  arising  from  imperfect  assimilation,  and  that  from  insufficient 
food. 

d.  Special  forms  of  amemia  are  directly  traceable  to  conditions  which,  without 
interfering  with  digestion  and  absorption,  seem  to  act  by  deteriorating  the  quality 
of  the  blood,  inducing  especially  disproportion  among  its  constituent  elements. 
Of  this  kind  are  the  effects  of  cancer  and  of  disease  of  the  kidney:  to  the  same 
class  we  must  refer  chlorosis  and  leucocythaamia.  All  these  subjects  must  again 
occupy  our  attention  in  considering  various  regions  of  the  body:  meanwhile  it  is 
only  needful  to  remark,  that  the  anaemia  is  rather  an  accidental  symptomin  the 
case  of  Gancer  and  albuminuria,  but  is  an  essential  one  in  chlorosis  and  white-cell 
blood:  in  the  latter,  too,  it  serves  to  draw  our  attention  to  the  spleen,  au^we  have 
no  other  direct  evidence  of  splenic  disease. 

In  cancer  the  pallid  appearance  is  combined  with  a  sallow  hue,  which  has  been 
called  the  "malignant  aspect;"  in  disease  of  the  kidney  there  is  usually  some  puf- 
finess  of  the  face,  and  the  cheeks  are  occasionally  mottled;  in  chlorosis,  as  its  name 
implies,  there  is  a  slight  tinge  of  green,  with  a  transparency  of  skin  which  makes 
the  face  look  like  a  wax  model;  in  leucocythzemia  the  aspect  is  muddy,  earthy, 
and  a  similar  appearance  may  be  seen  in  the  tuberculous  cachexia  of  early  life. 
These  differences  well-marked  in  advanced  cases,  and  frequently  sufficient  to  an 
experienced  eye  for  the  discrimination  of  the  disease,  must  not  be  much  relied  on 
by  the  student.  They  are  to  be  regarded  simply  as  aids  to  diagnosis,  not  as  the 
grounds  on  which  it  is  based. 

In  rare  cases  none  of  the  conditions  just  mentioned  can  be  made 
out  as  having  had  any  share  in  the  production  of  ansemia :  even  when 
fatal,  no  organic  disease  has  been  detected.  This  anemia  is  of  slow 
development;  it  seems  to  exist  alone,  and  is  marked  by  no  symptoms 
except  such  as  are  referrible  to  a  deterioration  of  the  circulating 
fluid.  For  the  present  we  must  rest  satisfied  with  determining  its 
presence  and  ascertaining  that  it  is  uncomplicated ;  we  cannot  get 
beyond  the  fact  which  the  name  anccmia,  or  spanremia,  as  used  by 
some  pathologists,  implies. 

The  general  state,  from  whatever  cause  derived,  is  followed,  in 
most  cases,  by  the  symptoms  already  enumerated — dyspnoea  and 
palpitation,  headache  and  general  weakness,  and  frequently  by 
emaciation,  the  latter  being  least  observed  in  those  associated  with 
hemorrhage  and  chlorosis.  Having  got  the  clue  from  the  objec- 
tive phenomenon  of  aspect,  we  have  only  to  observe  what  are  pri- 
mary and  what  secondary  affections  among  the  symptoms  present. 
The  pulse  is  pretty  full  when  the  change  is  rather  in  quality  than 
quantity;  if  weak  and  small,  there  is  certainly  deficient  amount  of 
blood;  with  a  soft  pulse— both  conditions  are  probably  present. 
The  tongue  is  very  generally  clean,  always  remarkably  pale,  and 
sometimes  slightly  furred  and  inclined  to  be  cedematous,  bearing 


CHLOROSIS.  103 

marks  of  the  teeth  on  its  edge.  The  coincidence  of  depraved  appe- 
tite and  irregular  bowels  with  anaemia  is  rather  the  rule  than  the 
exception.  Local  congestions  of  various  organs  are  very  frequently 
met  with,  and  the  full  recognition  of  the  general  condition  of  anae- 
mia  is  essential  to  the  rational  treatment.  The  association  of  oede- 
ma is  also  not  uncommon;  probably  every  case  of  anemia,  at  an 
advanced  stage,  would  become  more  or  less  dropsical  in  circumstances 
favourable  for  its  development ;  but  we  must  be  particularly  careful 
in  investigating  the  origin  of  this  symptom,  and  must  not  rest  satis- 
fied with  the  ready  explanation  that  the  condition  of  anaemia  offers, 
till  all  the  other  causes  of  its  existence  are  fully  examined.  (See 
Chap.  VII.,  Div.  i.,  §  1,  Anasarca.) 

§  8.  Chlorosis. — Although  essentially  a  form  of  anaemia  this  con- 
dition demands  separate  notice,  from  its  peculiar  association  with 
perverted  function  of  the  uterus.  It  seems  to  exist  under  two  pri- 
mary forms:  (a)  previous  anaemia,  followed  by  scanty  menstruation, 
terminating  in  complete  suppression  of  the  menses;  (b)  sadden  sup- 
pression of  the  menses,  terminating  in  general  alteration  of  the 
blood;  the  aspect  betraying  something  more  than  mere  anaemia. 

In  the  former  case,  the  limits  of  the  disease  are  not  well  defined; 
in  the  latter,  the  peculiar  characters  are  unmistakeable :  but  in  both 
there  is  some  specific  relation  between  the  symptoms,  and  in  order 
to  constitute  chlorosis  this  relation  must  be  clearly  made  out. 

Suppression  of  the  menses  under  the  name  of  amenorrhcea  be- 
longs especially  to  the  diseases  or  disorders  of  the  uterus.  Any  fe- 
male may  be  anaemic  from  some  one  of  the  causes  already  enume- 
rated, and,  as  a  casual  result  of  debility,  the  catamenia  may  be 
scanty  or  absent;  but  this  ought  not  to  be  called  chlorosis;  neither 
should  the  name  be  given  to  amenorrhcea  when  there  is  no  condition 
of  anaemia  associated  with  it.  But  when,  in  a  young  person,  there 
is  no  distinct  cause  for  the  anaemia,  and  when  along  with  it,  defi- 
ciency of  the  menstrual  flux  occurs  early,  and  total  suppression  soon 
follows,  or  when  suppression  precedes  anaemia,  the  classification 
seems  legitimate  and  useful. 

§  4.  Ansemic  Blood-murmurs. — The  diseases  which  Ave  have  just 
been  considering  are  characterized  by  a  deficiency  of  red  blood. 
W hen  the  condition  is  produced  by  a  change  in  quality  rather  than 
quantity,  when  the  red  globules  are  diminished  greatly  out  of  pro- 
portion to  the  loss  of  other  constituents  of  the  blood,  unnatural 
sounds  are  often  to  be  heard  with  the  stethoscope  at  various  points 
in  the  course  of  the  circulation;  over  the  heart,  the  arteries,  or  the 
large  veins,  while  there  is  but  little  obstruction  to  the  current  to 
account  for  their  production.  This  subject  must  be  again  referred 
to  in  speaking  of  diseases  of  the  heart  and  great  vessels;  but  its 
importance  seems  to  justify  a  few  words  here  to  point  out  to  the 
student  how  he  may  make  himself  acquainted,  so  far  as  possible, 
with  the  diagnosis  of  a  "blood-sound." 


104  CHRONIC    BLOOD   AILMENTS. 

The  essential  point  which  must  ever  be  borne  in  mind  is,  that  all 
"bruits"  whatever  are  produced  chiefly  in  the  blood  itself,  and  not 
in  the  solid  structures;  they  are  supposed  to  depend  on  vibrations 
among  the  particles,  or  globules;  the  sound  is  really  quite  independ- 
ent of  the  nature  of  the  disease  in  which  it  is  heard,  although  modi- 
fied  by  it,  as  it  causes  alterations  of  form  in  the  channels,  or  simply 
gives  rise  to  changes  in  the  qualities  of  the  blood.  Such  vibrations 
may  be  produced  in  any  fluid  by  placing  some  obstruction  in  the 
course  of  its  movements,  and  much  more  readily  in  thin  fluids  than 
in  those  which  arc  more  tenacious.  The  aptitude  for  their  produc- 
tion in  disease  therefore  varies  with  the  quality  of  the  blood,  and 
the  chance  of  their  occurrence,  with  the  condition  of  the  solid  struc- 
tures. In  a  perfectly  healthy  condition  of  the  blood  they  can  only 
be  produced  by  changes  of  certain  amount  in  the  form  and  calibre 
of  the  passages,  or  by  counter-currents ;  in  slight  deviation  from 
health,  less  important  alterations  will  serve  to  throw  the  particles 
into  vibration;  in  the  more  advanced  forms  of  anremia,  even  the 
natural  diiHculties  which  it  has  to  overcome  in  passing  through 
channels  of  varying  size  is  sufficient  to  produce  the  effect,  which  will 
be  more  or  less  marked  in  proportion  to  the  force  and  rapidity  of 
the  circulation.  No  such  phenomenon  is  observed  in  health,  simply 
because  a  due  proportion  exists  between  the  tenacity  of  the  fluid 
and  the  form  of  its  canals. 

Bearing  in  mind  these  different  elements  in  the  production  of  the 
sound,  it  will  be  readily  understood  that  no  certain  diagnosis  of  the 
nature  of  the  disease  can  be  formed  from  its  tone  or  intensity.  Ge- 
nerally speaking,  those  which  are  unaccompanied  by  structural 
change  have  a  very  decided  character  of  softness;  but  this  is  by  no 
means  peculiar  to  murmurs  of  this  class.  On  the  other  hand,  in 
considering  the  locality  in  which  it  is  heard,  we  have  to  remember 
that  the  true  blood-sound  is  only  secondarily  dependent  on  local 
causes,  because  we  know  cl  priori  that  a  very  slight  impediment  is 
sufficient  for  its  production;  and  it  is  reasonable  to  expect  that,  if 
any  circumstance  give  rise  to  its  presence,  it  will  be  heard  most  rea- 
dily where  the  current  is  most  superficial.  Another  consideration 
affecting  its  situation  is,  that  when  the  blood  is  thus  liable  to  be 
thrown  into  sonorous  vibration,  the  sound  is  propagated  in  every 
direction,  after  it  has  flowed  past  any  trifling  obstacle,  to  a  much 
greater  extent  than  when  healthy  blood  is  forced  into  the  same  vi- 
bration by  some  more  powerful  cause.  Accordingly,  we  find  it  very 
readily  produced  by  slight  pressure  on  a  blood-vessel ;  e.  g.,  the  ca- 
rotid artery:  again,  in  traversing  the  heart,  the  blood  passes  through 
channels  of  varying  size,  and  it  is  churned  and  mixed  together  in 
the  ventricles  in  such  a  way  as  would  naturally  lead  to  the  produc- 
tion of  "anaemic  murmurs,"  whether  on  the  right  or  the  left  side: 
the  pulmonary  artery  is  most  superficial  in  the  chest,  and  therefore 
the  sound  is  more  frequently  heard  there;  but  when  the  apex  of  the 
heart  comes  much  forward,  and  its  base  is  thrown  back,  the  arteries 


CACHEXIA.  105 

being  deeply  covered  by  lung-structure,  the  murmurs  may  be  best- 
heard  through  its  walls,  and  even  towards  its  apex.  In  decided 
ansemia,  a  blood-sound  can  also  be  heard  in  the  veins;  a  little  ma- 
nagement in  tilting  over  the  stethoscope  towards  the  patient's  head, 
so  as  partially  to  impede  the  returning  current  through  the  jugular 
veins,  will  generally  develop  this  venous  hum.  It  differs  from  the 
arterial  blood-sound  in  being  continuous,  and  not  intermittent:  its 
tone  varies  in  different  individuals;  but  the  best  general  idea  of  its 
character  may  be  obtained  from  the  roaring  of  a  large  shell,  applied 
to  the  ear;  it  is  called  by  the  French  "bruit  de  diable,"  from  the 
sound  of  the  humming-top;  but  this  is  both  louder  and  shriller. 
Both  sounds  may  often  be  heard  together  in  the  neck,  as  pressure 
is  made  with  the  edge  of  the  stethoscope  next  to  the  thorax,  or  the 
most  distant  from  it — more  firmly,  so  as  to  s|op  the  venous  current 
altogether — or  more  gently,  so  as  merely  to  impede  it.  When  the 
experiment  is  well  performed,  the  short  whiff  of  the  arterial  sound 
contrasts  strikingly  with  the  prolonged  continuous  hum  of  the  vein. 
If  the  venous  murmur  be  heard,  there  can  be  no  doubt  that  the 
blood  is  in  a  condition  in  which  bruits  are  readily  produced.  The 
same  conclusion  may  be  safely  arrived  at  if  slight  pressure  on  an 
artery  develop  a  short  whiff,  which  seems  close  to  the  ear,  is  syn- 
chronous with  the  pulse,  and  ceases  to  be  heard  when  the  pressure 
is  removed.  Similarly,  but  not  so  certainly,  may  a  blood-sound  be 
diagnosticated  if  it  occupy  the  whole  of  the  region  of  the  base  of 
the  heart,  being  especially  audible  in  the  pulmonary  artery,  where 
the  blood  is  generally  most  superficial,  but  evidently  not  confined 
to  that  locality. 

§  5,  Cachsemia,  or  Cachexia. — Mal-nutrition  may  exist  without 
the  remarkably  ex-sanguine  hue  of  aniemia,  under  the  form  simply 
of  general  derangement  of  health;  there  is  perhaps  emaciation,  with 
a  tendency  to  ill-defined  cutaneous  eruptions;  wheals  on  the  finders, 
resembling  chilblains,  and  afterwards  forming  watery  blebs  or  blains 
secreting  purulent  fluid ;  unhealthy  pustules  on  the  lower  limbs, 
&c,  and  yet  no  organ  gives  any  distinct  evidence  of  disease.  This 
condition  is  apt  to  be  generated  by  improper  or  insufficient  food,  ill- 
ventilated  apartments,  and  all  those  conditions  to  which  the  poorer 
artisans  in  large  towns  are  exposed.  On  the  other  hand,  cachsemia 
may  assume  a  more  definite  character  from  the  previous  accident 
of  a  poisoned  wound;  and  while,  as  a  general  rule,  inflammation  of 
the  absorbents  is  the  more  common  consequence,  yet  we  do  occa- 
sionally meet  with  cases  in  which  the  whole  circulating  fluid  appears 
to  be  deteriorated  in  its  qualities. 

The  general  class  is  an  unimportant  one,  because  in  a  great  many 
instances,  some  definite  malady  may  be  detected  as  the  basis  of  the 
depraved  state  of  the  blood, — scrofula,  disease  of  the  kidney,  con- 
genital syphilis,  &c.  Of  such  states  nothing  more  need  now  be 
said;  but  there  is  one  form  of  cachsemia  which  is  well  marked,  and 


106  CHRONIC    BLOOD    AILMENTS. 

of  grave  import:  it  is  characterized  by  contamination  of  the  blood 
from  an  admixture  of  pus, — pyaemia,  or  pyohsemia.  Not  unfrc- 
quently  arising  in  unhealthy  subjects  after  operation,  it  has  been 

lied  that  the  pus  secreted  in  the  wound  actually  finds  its  way 
into  the  blood;  but  it  is  by  no  means  limited  to  such  cases,  and  is 
constantly  mot  with  under  circumstances  in  which  there  is  no  chan- 
nel  by  which  the  pus  globules  could  find  their  way  into  the  circu- 
lating system.  Its  probable  source  in  all  cases  is  the  lining  mem- 
brane of  the  veins,  which  puts  on  a  form  of  suppurative  inflamma- 
tion, and  secretes  pus;  this  is  washed  into  the  general  current  of 
the  circulation,  and  so  produces  purulent  contamination  of  the  blood ; 
its  existence  must  therefore  be  secondary  to  a  form  of  phlebitis.  We 
find  it  as  a  sequence  of  almost  any  extensive  suppuration,  but  more 
especially  after  diffuse  cellular  inflammation.  It  very  rarely  ap- 
pears at  the  termination  of  phlegmasia  dolens,  the  "white-leg"  of 
parturient  females,  a  form  of  phlebitis  unattended  with  suppuration. 
This  circumstance  seems  to  negative  the  idea  of  its  existence  being 
ever  due  to  the  absorption  of  pus;  because  the  direct  admixture  of 
pus  with  the  blood  has  been  shown  to  produce  its  coagulation,  and 
the  phlebitis  of  child-birth  probably  arises  in  this  very  way,  from 
the  entrance  of  unhealthy  fluid,  purulent  or  sanious,  into  the  open 
mouths  of  the  uterine  veins.  The  condition  which  we  call  pyaemia 
must  therefore  have  some  different  cause,  and  none  appears  more 
rational  than  that  the  pus  is  secreted  from  the  lining  membrane  of 
the  veins. 

The  history  of  the  case  is  therefore  important;  but  most  com- 
monly the  disease  commences  under  the  practitioner's  own  eye, 
because  it  supervenes  on  one  which  has  already  required  medical 
treatment.  Sometimes,  however,  the  cause  of  the  primary  suppu- 
ration has  been  so  insidious  and  obscure,  that  the  first  evidence  of 
the  presence  of  pus  is  derived  from  its  general  diffusion  through  the 
blood.  It  is  marked  by  fever  of  an  adynamic  type,  quick  feeble 
pulse,  dry  brown  tongue,  shivering,  often  intense,  followed  by  co- 
pious perspirations.  These  are  only  the  general  signs  of  extensive 
suppurative  action,  and  it  is  to  be  presumed  that  they  indicate  a  fur- 
ther formation  of  pus,  not  improbably  in  the  blood  itself,  but  still 
more  certainly  in  the  various  organs  in  which  what  are  called  se- 
condary deposits  are  found.  These,  in  their  turn,  become  the  di- 
rect evidence  of  pyaemia:  the  pus  is  believed  to  be  obstructed  in  its 
passage  through  the  capillary  vessels,  and  at  each  point  where  it 
rests  to  become  a  focus  of  inflammation  which  rapidly  terminates  in 
a  small  abscess. 

"When  seated  in  internal  organs,  the  existence  of  secondary  de- 
posits can  only  be  inferred  from  the  previous  knowledge  of  suppu- 
ration elsewhere,  taken  in  conjunction  with  the  general  evidence  of 
its  extension,  and  the  local  symptoms  of  pain  or  altered  function  in 
the  particular  organ.  Those  most  liable  to  be  so  affected  are  the 
lungs  and  liver,  and  secondary  deposits  are  rarely  found  elsewhere 


CACH^MIA.  107 

without  their  being  also  found  in  them.  Very  often,  however,  the 
suppuration  takes  place  near  the  surface;  it  commences  with  a 
patch  of  intense  redness  on  the  skin,  accompanied  by  but  little  ten- 
sion or  tenderness,  and  thus  proving  that  the  inflammatory  action 
is  of  a  very  low  type ;  it  passes  in  a  few  hours  perhaps,  into  suppu- 
ration and  abscess,  becoming  soft  and  fluctuating.  Erythema  no- 
dosum occasionally  presents  characters  which  might  be  readily  mis- 
taken for  the  early  stage  of  these  small  abscesses;  the  previous 
history  ought  to  preserve  us  from  such  a  mistake,  and  the  course  of 
the  disease  will  soon  clear  up  any  doubts  that  may  have  remained. 
In  cases  of  erythema  the  redness  probably  acquires  a  bluish  tint,  or 
remains  unchanged,  and  though  the  swelling  feel  soft,  there  is  no 
fluctuation  and  no  formation  of  pus. 

In  other  instances  the  presence  of  pus  in  the  blood  leads  to  the 
formation  of  small  pustules  on  the  skin  itself;  not  very  numerous, 
they  are  prominent,  fill  rapidly,  do  not  pass  through  any  prelimi- 
nary stage  of  serous  exudation,  but  evidently  from  the  first  contain 
purulent  fluid:  they  can  only  be  confounded  by  a  very  superficial 
observer  with  a  varioloid  eruption.  These  two  forms  of  deposit  are 
each  very  characteristic,  and  are  generally  associated  with  larger 
collections  of  pus  around  the  joints,  or  spread  abroad  in  the  cellu- 
lar tissue  and  burrowing  among  the  muscles.  In  the  absence  of  the 
pustules  and  small  abscesses  just  mentioned,  the  inflammation  around 
the  joints  may  be  mistaken  for  acute  rheumatism,  which  it  simu- 
lates in  attacking  several  in  succession;  but  it  will  be  observed 
that  the  swelling  is  very  much  more  extensive,  and  the  redness  more 
erysipelatous-looking  than  ever  happens  in  rheumatism.  This  is 
caused  by  the  tendency  to  diffuse  cellular  inflammation,  which  gene- 
rally also  shows  itself  in  other  parts,  at  a  distance  from  any  joint, 
over  the  thorax,  about  the  eyes  and  face,  &c. 

Cases  of  pyaemia  bear»a  close  analogy  in  many  respects  to  glan- 
ders, and  when  the  primary  suppuration  cannot  be  discovered,  they 
are  somewhat  perplexing.  A  sallow  aspect,  and  a  peculiar  odour 
of  the  breath  have  been  both  urged  as  characteristic  of  the  disease ; 
but  while  they  may  aid  the  diagnosis,  they  cannot  be  made  the 
principal  grounds  of  discrimination. 


v> 


CHAPTER  IX. 

DEPRAVED    CONSTITUTIONAL    STATE?. 

Div.  I. — Scrofula  and  Tubercles. — §  1,  Scrofula — §  2,  Tabes  Me- 
senterial— §  3,  Phthisis — Acute  and  Chronic — §  4,  Tubercles  in 
the  Peritoneum — §  5,  Tubercles  in  the  Brain. 

Div.  II. — Morbid  Growths. — §  1,  Of  Local  Enlargements — their 
Causes — §  2,  Of  the  Locality  of  Tumours — on  the  Surface  gene- 
rally— on  the  Head — in  the  Neck — the  Chest — the  Abdomen — 
§  3,  Of  the  Nature  of  Tumours — Cystic  Growths — Encephaloid 
— Scirrhus — Colloid —  Osseous  Growths. 

Division  I. — Scrofula  and  Tubercles. 

§  1.  Scrofula. — There  are  some  specific  forms  of  mal-nutrition, 
derived,  in  all  probability,  in  a  majority  of  instances,  from  heredi- 
tary taint,  of  which  the  scrofulous  and  the  tubercular  diatheses  are 
the  most  important.  Along  with  general  derangement  of  health 
and  imperfect  growth  of  structure  in  childhood,  the  lymphatic 
glands  tend  to  enlarge  and  to  form  an  ill-organized  yellow  deposit 
in  their  interior,  which  readily  suppurates,  and  yields  unhealthy 
pus.  This  condition  is  most  readily  noted  in  the  superficial  glands 
of  the  neck,  where  casual  exposure  to  cold  is  very  likely  to  excite 
the  quasi-inflammatory  action  which  leads  to  the  enlargemgnt. 

The  history  of  the  case  probably  shows  that  the  child  was  always 
delicate,  suffering  more  than  usual  from  teething,  perhaps  liable  to 
convulsions ;  or,  if  itself  healthy,  other  members  of  the  same  family 
have  suffered  in  this  way.  The  ailment  comes  on  insidiously,  with- 
out any  assignable  cause ;  and  when  first  seen,  there  may  be  un- 
healthy discharges  of  an  acrid  and  semipurulent  character  from  the 
eyes  and  nose ;  or  abscesses  may  have  formed  on  various  parts  of 
the  body,  of  an  indolent  character,  which,  when  they  open,  leave 
unhealthy  ulcers.  Very  often  cutaneous  eruptions,  particularly  of 
an  impetiginous  character,  are  found  spread  over  the  head  and  face; 
these  are  obstinate  and  intractable,  and  are  not  unfrequently  the 
cause  of  the  enlargement  of  the  cervical  glands.  To  this  general 
state  we  give  the  name  of  scrofula. 

The  tongue  is  often  habitually  coated,  and  the  intestinal  discharges 
unhealthy;  such  children  are  very  liable  to  be  infested  with  asca- 
rides;  the  aspect  is  generally  characteristic;  the  skin  is  clear  and 
thin,  the  face  often  anaemic;  the  limbs  soft  and  flaccid,  and  the 
belly  tumid;  the  upper  lip  is  sometimes  thickened  and  projecting, 
but  this  would  appear  to  be  chiefly  a  result  of  acrid  discharges  from 
the  nostrils.  A  scrofulous  child  may  very  readily  become  tuber- 
cular, but  the  two  diseases  are  seldom  fully  developed  together. 


DEPRAVED    CONSTITUTIONAL    STATES.  109 

§  2.  Tabes  Mesenterka. — Sometimes,  in  conjunction  with  some 
of  the  external  symptoms  of  scrofula,  emaciation  proceeds  to  a 
greater  extent  than  usual;  the  limbs  dwindle,  the  skin  becomes  dry 
and  shrivelled,  the  abdomen  is  hard  and  tense,  and  the  little  patient 
appears  to  suffer  pain  when  pressure  is  made ;  the  evacuations  are 
very  offensive,  and  the  bowels  irregular  in  their  action;  there  is  a 
tendency  to  diarrhoea,  which  may  become  urgent  and  obstinate.  In 
such  a  case  we  have  great  reason  to  believe  that  scrofulous  or  tuber- 
cular matter,  or  a  mixture  of  both,  in  what  has  been  called  scrofu- 
lous tubercle,  has  been  deposited  in  the  glands  of  the  abdomen,  and 
especially  in  the  mesenteric  glands:  hence  the  name  tabes  mesen- 
terica  has  been  applied  to  this  form  of  the  scrofulous  cachexy. 

§  3.  Phthisis. — True  tubercle  has  the  peculiarity  of  being  chiefly 
developed  in  the  lungs:  it  may  exist  in  other  internal  organs,  but 
it  is  very  unusual  in  such  cases  to  find  the  lungs  wholly  exempt.  Its 
commencement  is  always  insidious,  and  its  subsequent  progress  is 
sometimes  tardy;  but,  more  commonly,  it  proceeds  with  considera- 
ble rapidity. 

This  circumstance  has  given  rise  to  the  division  into  acute  and 
chronic  phthisis;  the  distinction  being  based  upon  the  extent  of 
structure  simultaneously  attacked',  and  the  rapidity  with  which  it 
spreads  to  surrounding  parts,  and  not  on  any  difference  in  the  na- 
ture of  the  disease.  It  is  practically  useful  because  of  the  diffe- 
rent train  of  symptoms  set  up  by  a  speedy  invasion  of  the  whole 
lung,  or  a  gradual  disintegration  of  successive  portions  of  it.  Ex- 
posed as  all  ages  are  to  the  ravages  of  this  disease,  it  especialty 
prevails  soon  after  puberty,  when  both  forms  are  constantly  ob- 
served, and  seem  to  merge  into  each  other.  In  elderly  persons  acute 
tuberculization  never  occurs;  and,  on  the  other  hand,  it  may  at  least 
be  said  that  true  chronic  phthisis  is  extremely  rare  in  children. 

The  acute  form  sets  in  as  an  attack  of  influenza — that  is  to  say, 
with  symptoms  of  bronchial  irritation  and  adynamic  fever,  the  pre- 
ceding coryza,  however,  being  generally  absent.  This  condition 
becoming  persistent,  the  pulse  continues  rapid  and  feeble;  the 
cheeks  are  flushed;  perspirations  occur,  especially  at  night;  ema- 
ciation and  increasing  weakness  follow  in  rapid  succession,  even 
before  any  physical  signs  in  the  lungs  themselves  indicate  the  pre- 
sence of  tubercular  matter. 

The  full  consideration  of  this  subject  can  only  be  entered  upon 
after  the  physical  signs  of  disease  of  the  lungs  are  detailed ;  here 
we  have  only  to  do  with  the  general  features  of  the  diathesis. 
"While  the  pulse  is  quick,  the  condition  of  the  skin  alternates  be- 
tween dryness  and  moisture,  is  never  harsh  or  burning,  as  in  fever, 
and  the  perspirations  are  sometimes  excessive;  the  state  of  the 
tongue  is  very  various;  and  the  bowels  may  be  either  natural  in 
action  or  inclined  to  diarrhoea;  the  aspect  is  often  instructive;  a 
certain  degree  of  anaemia  prevails,  with  a  bright  colour  on  the 


110     DEPRAVED  CONSTITUTIONAL  STATES. 

checks;  the  eyes  are  soft  and  brilliant,  with  large  pupils,  and  fre- 
quently fringed  by  long  eyelashes;  this  is  especially  to  be  seen  in 
childhood.  The  accompanying  emaciation,  and  the  languid  manner 
and  sense  of  feebleness,  afford  additional  grounds  for  a  suspicion  of 
the  presence  of  tubercle. 

In  its  early  stages  accurate  diagnosis  is,  perhaps,  impossible,  even  with  the 
aid  of  physical  signs;  in  children  the  supervention  of  such  a  state  upon  measles 
is  most  probably  due  to  this  cause,  especially  if  the  patient  have  previously  suf- 
fered from  any  of  the  symptoms  of  scrofula,  or  if  scrofula  or  phthisis  exist  iu 
the  family  of  either  of  the  parents,  or  have  been  evidenced  in  others  of  the 
children.  The  absence  of  coryza  in  the  first  onset  of  the  disease,  points  to  some 
local  cause  of  bronchial  irritation,  and  not  to  a  general  affection  of  the  mucous 
membrane  J  the  persistence  of  adynamic  fever  shows  that  the  attack  is  not  one  of  in- 
fluenza or  bronchitis  properly  so  called,  in  each  of  which  the  febrile  state  is  more 
transient;  the  condition  of  the  tongue  is  seldom  that  of  common  continued  fever, 
it  is  only  at  an  advanced  stage  that  it  presents  at  all  the  patchy  redness  or  chapped 
appearance  of  fever  accompanied  by  diarrhoea,  and  it  is  very  seldom  dry;  indeed 
it  is  rather  aphthous  or  ulcerated  than  patched  and  chapped :  the  recurrence  of 
perspirations  is  also  unusual  in  fever.  The  whole  characters  of  the  case  are  more 
closely  allied  to  those  presented  in  a  tardy  convalescence,  and  then  the  previous 
history  of  an  acute  attack  with  much  thirst,  loss  of  appetite,  wandering  delirious 
nights,  &c,  is  quite  different  from  the  history  of  a  gradually  increasing  malady; 
but  it  must  be  remembered,  on  the  other  hand,  that  the  debilitating  effects  of  an 
attack  of  fever  predispose  to  the  incursion  of  tubercles,  and  it  may  be  impossible 
to  say  when  the  one  has  terminated  and  the  other  begun. 

The  march  of  chronic  phthisis  is  always  insidious.  Here  the 
deposit  of  tubercles  is  much  more  local  aud  more  easily  made  out 
by  a  physical  examination  of  the  chest;  but  in  the  earlier  stages 
the  signs  may  be  dubious,  or  null.  The  more  important  general 
symptoms  are  emaciation,  night-sweats,  and  hemoptysis ;  when  these 
exist  along  with  a  dry  hacking  cough,  wandering  pains  in  the  chest, 
an  habitually  quick  pulse,  a  degree  of  huskiness  of  the  voice,  and 
diarrhoea,  scarcely  a  doubt  can  remain  that  the  disease  has  com- 
menced, even  though  the  stethoscopic  signs  be  very  obscure.  It  is 
remarkable  how  unwilling  patients  generally  are  to  confess  to 
"  spitting  of  blood; "  and  when  the  amount  has  been  trifling,  it  may 
require  much  cross-questioning  to  elicit  the  truth.  As  it  proceeds, 
the  hectic  flush  on  the  cheeks  contrasts  strangely  with  the  clear, 
transparent  pallor  of  the  rest  of  the  face ;  the  eyes  are  often  bright 
and  luminous ;  the  skin  becomes  soft  and  velvety,  and,  when  pinched 
up,  is  found  to  be  thin,  and  detached  from  the  subjacent  muscles; 
the  ends  of  the  fingers  become  clubbed,  and  the  nails  unciform; 
the  gait  is  stooping;  the  shoulders  curved  forwards;  the  chest  flat- 
tened, and  but  little  expanded  in  breathing ;  while  every  movement 
of  the  body  gives  token  of  feebleness  and  languor. 

Any  of  these  symptoms  may  be  absent,  and  on  a  just  appreciation  of  their  col- 
lective value  often  depends  the  correctness  or  incorrectness  of  diagnosis.  Ema- 
ciation is  never  wanting,  but  is  often  associated  with  other  affections,  of  which 
cough  may  be  a  concomitant:  night-sweats,  though  more  frequent  in  this  disease 
than  any  other,  may  be  merely  the  effect  of  debility:  haemoptysis  does  generally 
appear  at  some  time  or  other  in  chronic  phthisis,  but  not  necessarily  so,  and  the 
disease  has  already  made  some  progress  in  most  cases  before  the  symptom  is  seen; 


SCROFULA  AND  TUBERCLES.  Ill 

when  present,  and  there  is  no  disease  of  the  heart  to  account  for  it,  and  it  cannot 
be  explained  as  the  result  of  hysteria,  or  as  vicarious  of  menstruation,  it  is  more 
to  be  relied  on  as  an  indication  of  phthisis  than  any  other.  A  dry,  hacking  cough 
without  expectoration,  or  with  mixed  mucilaginous-looking  sputa,  where  it  is  ac- 
companied by  pains  in  the  chest,  aud  there  has  been  neither  coryza  nor  sore  throat. 
to  indicate  a  simultaneous  affection  of  the  whole  mucous  membrane,  may  be  very 
safely  set  down  as  having  a  tubercular  origin.  HusSiness  of  the  voice,  caused  by 
slight  laryngeal  affection,  derives  its  sole  value  from  its  association  with  other 
symptoms;  but  it  may  owe  its  existence  to  previous  syphilis,  it  may  be  simply  due 
to  an  ordinary  cold  with  sore  throat,  or  it  may  even  be  caused  by  pressure  on  the 
trachea  or  larynx.  An  habitually  quick  pulse,  when  coinciding  with  cough  and 
other  indications  of  affection  of  the  chest,  is  exceedingly  suspicious  ;  but  both  may 
be  caused  by  obscure  disease  of  the  heart,  and,  on  the  other  hand,  phthisis  has 
often  proceeded  to  its  most  advanced  stage  without  this  symptom  being  present  at 
all.  Diarrhoea  tends  greatly  to  confirm  our  fears,  because,  although  there  be  no 
specific  ground  on  which  its  tubercular  origin  can  be  determined,  yet  the  liability 
to  it  is  greater  in  phthisis  than  in  any  other  disease,  except  common  continued 
fever;  in  both  a  specific  affection  of  the  intestinal  glands  exists.  The  further 
symptoms  are  those  of  hectic  fever,  and  its  accompanying  emaciation  ;  and  as  such 
they  generally  serve  to  stamp  the  phthisical  character  of  cough,  but  they  may  be 
very  closely  simulated  in  cases  of  persistent  bronchitis. 

The  correct  diagnosis  of  phthisis  depends  upon  the  harmony  of  general  symp- 
toms and  physical  signs,  and  while  a  complete  array  of  symptoms,  or  very  strong 
evidence  derived  from  signs,  may  lead  to  the  conclusion  that  in  all  probability 
this  disease  is  present,  a  combination  of  the  two  can  alone  justify  a  decided  opi- 
nion. To  this  subject  we  must  again  recur.  (See  Chap.  XX.,  \  9.  Phthisis  pul- 
monalis.) 

Much  attention  ought  to  be  given  to  the  liability  to  hereditary  transmission, 
which  certainly  in  some  families  is  very  marked;  strict  inductive  evidence  of  its 
relative  power  is  yet  wanting,  and  its  subordination  or  superiority  to  other  predis- 
posing causes  is  not  determined;  but  the  existence  of  scrofula  or  tubercles  in  the 
parent  is  a  sufficient  ground  for  leading  us  to  suspect  their  presence  in  the  child 
when  other  indications  point  in  that  direction. 

§  4.  Tubercles  in  the  Peritoneum. — Next,  perhaps,  in  frequency 
and  importance,  is  the  development  of  tubercle  in  the  peritoneum. 
In  children  it  sometimes  occurs  alone,  or  with  scrofulous  tubercle  in 
the  mesenteric  glands,  when  there  is  no  corresponding  deposit  in 
the  lungs :  in  adults  it  is  seldom  separable  from  phthisis.  Its  symp- 
toms are  those  of  peritonitis,  -which  will  be  detailed  in  a  subsequent 
chapter;  and  it  is  enough  to  say  here  that  the  tubercular  form  is 
to  be  distinguished  by  its  gradual  and  insidious  incursion,  and  by 
the  presence  of  general  symptoms  corresponding  to  those  seen  in 
phthisis,  if  due  allowance  be  made  for  the  difference  of  the  region 
in  which  the  tubercular  matter  has  been  developed.  Thus  there  are 
the  same  quickness  of  pulse,  accompanied  by  perspiration,  the  ema- 
ciation and  languid  feelings,  and  very  often  the  diarrhoea  of  early 
phthisis;  to  these  are  superadded,  a  sense  of  tension  in  the  abdo- 
men, which  has  a  tumid  feeling,  and  does  not  bear  pressure  without 
pain;  the  tongue  is  very  commonly  furred,  but  not  to  any  great 
degree.  Evidence  of  tubercle  in  the  lungs  is  of  much  value  in  aid- 
ing diagnosis ;  as  is  also  the  presence  of  diarrhoea,  because  it  is  less 
common  in  simple  peritonitis,  and  is  probably  caused  by  the  exist- 
ence of  tubercle  in  its  very  common  locality — the  solitary  glands  of 
the  intestine.    But  we  may  be  defeated  in  our  endeavour  to  form  a 


112  DEPRAVED     CONSTITUTIONAL    STATES. 

correct  diagnosis,  either  by  the  history  recording  that  the  attack 
has  been,  or  has  appeared  to  be,  sudden,  or  by  limited  suppuration, 
in  the  form  of  deep-seated  and  confined  abscess  of  the  peritoneum, 
producing  symptoms  of  hectic.  To  this  it  must  be  added,  that 
perplexing  symptoms  sometimes  present  themselves  as  the  effects  of 
pressure  on  the  nerves,  the  blood-vessels,  or  the  absorbents,  or  as 
the  more  remote  consequences  of  adhesions  between  the  various 
coils  of  intestine.  Perhaps  our  best  guide  is  to  be  found  in  the 
general  adynamic  character  of  the  symptoms  throughout,  and  in  the 
previous  existence  of  the  cachectic  state  which  preceded  them. 

des  in  the  Brain. — "When  we  come  to  diseases  of  the  brain,  we  shall 
have  to  discuss  a  form  of  meningitis,  which  is  unquestionably  related  to  the  scro- 
fulous and  tubercular  diathesis ;  clinical  observation  and  post-mortem  examina- 
tion alike  proving  that  inflammation  of  the  brain  attended  with  the  effusion  of  se- 
r  ,m,  and  hence  often  called  hydrocephalus  acutus,  is  constantly  associated  with 
the  presence  of  tubercle  in  other  organs.  We  shall  then  also  have  to  consider  the 
symptoms  which  may  result  from  the  actual  presence  of  a  tuberculous  deposit  in 
the  brain  itself:  but  we  may  remark  that  the  tubercle  is'often  solitary,  and  that  it 
mav  have  attained  a  very  considerable  magnitude  without  making  its  presence 
manifest  by  any  symptoms  until  the  more  acute  disease  supervene;  it  is  only  rarely 

lute  size  or  peculiar  position  impedes  by  pressure  the  transmission  of 
nervous  energy,  so  as  to  produce  paralysis  or  loss  of  sensibility. 

Division  II. — Morbid  Growths. 

§  1.  Of  Local  Enlargements. — Local  increase  of  size,  as  one  of 
the  objective  phenomena  of  disease,  requires  careful  study.  It  may 
be  found  in  any  part,  whether  of  the  trunk  or  the  extremities:  it 
embraces  the  whole  class  of  abnormal  growths,  but  it  may  also  be 
caused  by  hypertrophy  of  natural  structures  or  deposition  of  fat; 
or  it  may  be  clue  to  an  effusion  of  serum,  of  blood,  of  lymph,  or  of 
pus;  or  it  may  depend  on  periosteal  thickening  or  inflammation  of 
bone. 

In  simple  hypertrophy  there  are  no  symptoms  of  disease  present  except  those 
attendant  on  increase  of  size:  the  natural  structures  hold  their  due  relation  to  each 
other,  and  are  all  increased  in  equal  proportion. 

dipose  tissue  is  more  liable  to  general  than  to  local  increase.  It  is  in  the  ab- 
domen  where  its  accumulation  is  most  likely  to  occur;  the  parietes,  when  pinched 
up,  i  isibly  thicker  when  the  deposit  of  fat  is  in  the  subcutaneous  tissue,  and 

an  elastic  fulness  of  the  whole  region,  with  considerable  flaccidity,  is  given  by  its 
deposition  in  the  folds  of  the  omentum.  We  are  led  to  the  conclusion  that  this  is 
the  true  nature  of  such  an  enlargement  by  the  absence  of  indications  of  disease, 
beyond  the  existence  of  dyspeptic  symptoms,  and  by  the  persistence  of  general 
ndness  and  fulness  of  tlie  limbs  which  we  know  to  be  incompatible  with  organic 
ase. 

The  presence  of  serous  effusion  gives  rise  in  the  head  to  the  chronic  hydroce- 
phalus of  childhood,  with  its  unnatural  enlargement;   in  the  thorax  it  causes 
of  the  intercostal  spaces  and  enlargement  of  one  side  of  the  chest;  in  the 
abdomen  it  prod  rites  and  ovarian  dropsy;  in  the  scrotum  it  occurs  as  hy- 

drocele; in  the  limbs  it  is  the  evidence  of  general  dropsy  or  of  local  oedema. 

An  accumulation  of  blood  contained  within  the  distended  vessels  or  in  a  pouch 
communicating  with  them,  is  found  as  aneurism  or  varicocele.  When  extravasated 
it  quickly  c<  and  forms  a  firm  tumour  of  undefined  outline,  as  may  some- 

limes  be  seen  after  a  strain,  or  more  distinctly  in  the  testicle  as  hematocele;  within 


MORBID    GROWTHS.  113 

the  cavities  it  can  only  give  rise  to  symptoms  of  the  presence  of  tumour  when  it 
exists  as  an  aneurism. 

Effusion  of  lymph,  as  the  consequence  of  local  inflammation,  is  commonly  fol- 
lowed by  the  formation  of  pus;  but  it  may  remain  stationary  at  the  first  stage,  and 
be  removed  by  absorption,  the  tumefaction  being  very  generally  increased  by  the 
coexistence  of  serous  effusion  around.  Such  swellings  are  to  be  met  with  among 
the  muscles,  but  more  especially  in  the  lymphatic  glands. 

Pus  can  of  necessity  only  exist  after  inflammation  ending  in  suppuration ;  but 
yet  large  collections  of  matter  sometimes  form  when  the  signs  of  inflammatory  ac- 
tion are  almost  wholly  wanting,  and  this  is  especially  true  of  scrofulous  subjects. 
As  with  serous  effusion,  the  presence  of  pus  may  cause  bulging  of  one  side  of  the 
chest:  in  the  abdomen,  collections  of  pus  are  more  commonly  local,  and  limited 
by  surrounding  adhesions  of  the  peritoneum;  one  form  of  abdominal  suppuration 
is  entirely  without  the  peritoneal  cavity,  psoas  or  lumbar  abscess,  pushing  out- 
wardly over  the  edge  of  the  pubis  in  front  or  above  the  sacrum  behind.  In  addi- 
tion to  these  the  parietes  of  the  cavities  may  become  the  seat  of  local  collections 
of  pus,  from  diffuse  cellular  inflammation,  or  caries  of  bone.  Similar  events  oc- 
cur in  the  extremities,  and  especially  in  the  proximity  of  the  ends  of  the  long 
bones  of  scrofulous  children.  The  lumbar  abscess,  already  mentioned,  is  very  fre- 
quently connected  with  caries  of  the  spine.  Inflammation  of  the  glands  not  unfre- 
qiiently  terminates  in  abscess,  especially  in  scrofulous  subjects,  with  whom  those 
situated  in  the  neck  seem  more  liable  to  suppurate  than  any  others. 

Periosteal  thickening  and  inflammation  of  bone  are  more  commonly  met  with 
in  the  long  bones  of  the  extremities  than  elsewhere;  the  former  so  often  forming 
rounded  painful  nodes  on  the  shin-bone,  the  latter  giving  rise,  by  the  deposit  of 
fresh  osseous  matter,  to  enlargements  of  very  irregular  form  and  outline. 

The  details  of  many  of  these  subjects  belong  to  surgery;  the  remainder,  so  far 
as  diagnosis  is  concerned,  must  be  considered  with  reference  to  the  organs  or  re- 
gions in  which  they  exist. 

§  2.  Of  the  Locality  of  Tumours. — In  the  diagnosis  of  tumours, 
properly  so  called,  there  are  two  very  distinct  sets  of  symptoms, 
which  are  derived,  the  one  from  their  local  action  as  they  interfere 
with  function  by  mere  size  and  pressure,  the  other  from  their  gene- 
ral influence  upon  health;  the  former  common  to  all,  the  latter  be- 
longing especially  to  malignant  tumours.  It  is  therefore  necessary 
first  to  inquire  into  the  localities  in  which  they  are  found,  and  the 
evidence  of  their  presence  there,  although  this  cannot  be  wholly 
separated  from  a  consideration  of  their  nature. 

A  tumour  lying  superficially  with  reference  to  any  of  the  great 
cavities,  or  on  any  of  the  extremities,  leaves  no  doubt  as  to  its  ex- 
istence ;  one  that  is  deep-seated  in  the  abdomen,  when  its  margins 
can  be  felt,  or  its  resistance  detected  by  firm  pressure  with  the 
points  of  the  fingers,  may  be  recognised  with  equal  certainty;  on 
the  other  hand,  if  contained  within  the  cranium,  or  deep  in  the  tho- 
racic cavity,  and,  in  some  instances,  when  situated  close  to  the 
lumbar  vertebras,  its  existence  can  only  be  inferred  from  symptoms 
derived  from  the  organs  contained  in  the  cavities,  and  must  remain 
more  or  less  uncertain.  The  indications  are  most  indefinite  in  re- 
gard to  the  cranium ;  they  are  more  easily  made  out  when  the  tu- 
mour is  in  the  chest,  and  are  seldom  wholly  unaccompanied  by  more 
direct  evidence  when  situated  in  the  abdominal  cavity.  They  must 
each  be  discussed  in  considering  the  phenomena  peculiar  to  various 
8 


114  DETRAVED    CONSTITUTIONAL    STATES. 

organs  at  a  later  period;  and  for  the  present  we  must  assume  that 
the  tumour  is  palpable. 

It  is  of  importance  to  study  carefully  the  history  of  all  such 
cases.  In  some  it  will  be  found  that  the  symptoms  detailed  corre- 
spond with  the  commencement  and  development  of  the  tumour;  in 
others,  they  are  only  those  of  its  later  stages ;  while,  again,  the 
history  sometimes  points  to  a  totally  different  disease,  and  it  is 
only  while  pursuing  this  investigation  that  a  tumour  is  accidentally 
discovered.  This  division  corresponds  in  some  measure  to  real  dif- 
ferences of  character,  and  roughly  points  out  those  having  an  in- 
flammatory origin,  those  whose  character  has  more  or  less  of  malig- 
nancy, and  those  which  are  slow  in  their  growth,  and  comparatively 
harmless,  except  in  their  secondary  results.  To  this,  however, 
there  are  numerous  exceptions. 

When  the  patient  has  already  become  conscious  of  its  existence, 
we  seek  to  ascertain  its  specific  history  so  far  as  it  is  known  to  him, 
the  progress  of  its  development,  and  the  symptoms  which  have 
been  associated  in  his  own  mind  with  its  presence ;  as  well  as  those 
bearing  upon  the  general  state  of  health  and  the  affections  of 
other  and  more  distant  organs  which  have  been  observed  since  it 
was  first  recognised. 

In  a  class  so  extensive  as  tumours  it  is  vain  to  look  for  general 
symptoms  which  shall  characterize  the  whole  of  them,  but  there  are 
many  which  are  of  much  value  in  discriminating  the  nature  of  the 
disease,  and  the  special  locality  where  it  is  situated.  It  is  there- 
fore our  next  business  to  observe  each  of  those  circumstances  care- 
full}'- which  have  been  mentioned  as  indications  of  the  general  state 
of  the  patient.  Thus,  as  we  know  that  the  history  is  very  often 
faulty,  it  is  important  to  consider  whether  there  be  febrile  symp- 
toms, either  such  as  usually  accompany  inflammatory  action,  or 
those  more  distinctly  pointing  to  suppuration ;  or  whether  there  be 
only  the  quick  pulse  of  debility  or  tubercular  deposit.  Again,  we 
have  to  consider  the  appearance  of  the  patient,  calculating  how 
much  of  the  change  reported  is  due  to  the  presence  of  the  tumour, 
and  how  much  may  be  accounted  for  in  other  ways;  and  to  note 
whatever  strikes  the  eye  as  a  deviation  from  the  normal  ideal 
standard. 

This  part  of  the  inquiry  has  perhaps  to  do  more  with  the  nature  of  the  tumour 
than  its  locality.  Rapidity  of  growth  is  a  very  decided  indication  in  favour  of  ma- 
lignant disease;  such  are  also  the  evidence  of  general  derangement  of  health  and 
itions  of  distant  organs,  other  than  can  be  accounted  for  by  nervous  sympathy 
and  inter-communication;  they  show  the  existence  of  a  taint  of  the  blood  different 
from  what  accompanies  non-malignant  growths.  The  local  signs  of  greater  or 
less  derangement  of  function  in  contiguous  structures  have  also  an  important 
bearing  on  the  question.  The  aspect  of  the  patient  may  be  of  service  in  so  far 
as  the  physiognomy  of  disease  enables  us  to  discriminate  between  the  tuber- 
cular and  cancerous  diathesis  for  example.  Changes  of  colour,  again,  rather 
point  to  the  organ  in  which  the  disease  is  located.  These  general  considerations 
are  also  of  value,  as  they  afford  evidence  of  obstruction  to  the  nutrition,  or  the 
circulation,  in  different  parts  of  the  body.     Not  less  important,  sometimes,  are  the 


MORBID    GROWTHS.  115 

indications  derived  from  position,  as  the  patient  is  obliged  by  pain,  or  other  un- 
easy sensations,  to  maintain  a  fixed  posture,  or  to  prefer  one  to  another. 

We  have  next  to  note  the  relations  and  connexions  of  the  tumour 
itself;  with  the  skin,  with  muscles,  with  bone,  with  glands,  or  with 
internal  organs;  and  it  must  be  evident  that  very  much  will  depend 
on  the  correctness  of  the  antecedent  knowledge  of  the  observer. 
He  must  be  familiar  not  only  with  the  relations  of  deep-seated 
parts  in  health,  but  also  with  the  changes  of  position  that  they  are 
subject  to  in  disease,  inasmuch  as  the  direction  of  the  displacement 
may  serve  to  point  out  the  true  origin  or  starting  point  of  the 
tumour.  Not  less  needful  is  a  correct  knowledge  of  structure  and 
of  function,  in  order  that  he  may  be  able  to  distinguish  alteration 
of  form  from  change  of  position,  and  to  recognise  symptoms  of  dis- 
ease in  particular  viscera. 

The  simplest  form  in  which  we  can  recognise  the  existence  of  tumour  is  when 
swelling  is  the  result  of  inflammation,  with  effusion  of  lymph  and  serum,  which 
terminates  either  in  resolution  or  in  suppuration.  It  can  scarcely  be  mistaken  for 
growth  of  any  kind,  because  of  the  pain  and  superficial  redness  in  its  early  sta°-e- 
it  is  very  closely  adherent  to  the  skin  and  muscular  structures,  which  cannot be 
made  to  move  over  it.  In  the  iliac  region,  and  over  the  surface  of  the  chest,  such 
swellings  in  their  advanced  stage  are  apt  to  be  taken  for  growth  from  bone-  the 
diagnosis,  when  the  history  fails  to  indicate  the  origin  of  the  tumour,  rests  upon 
two  points,  viz.,  that  inflammatory  effusion  is  evenly  spread  out  among  the  mus- 
cular structures,  while  morbid  growth  presents  a  more  defined  edge;  and  that  the 
one  adhering  more  to  the  skin  can  be  made  to  move  over  the  bone,  while  the  other 
adhering  directly  to  the  bone,  does  not  become  attached  to  the  skin  till  it  has  at- 
tained considerable  magnitude.  In  the  chest,  we  may  be  also  guided  by  the  cii- 
cumstance  that  more  than  one  intercostal  space  is  equally  filled  up  by  superficial 
inflammatory  action,  whereas  the  fulness  is  almost  entirely  limited  to  one,  or  st 
most  two,  when  growth  of  any  sort  from  the  rib  is  its  cause,  until  its  size  is  such 
as  to  leave  us  in  no  doubt. 

Enlarged  synovial  bursa?,  and  lymphatic  glands,  give  rise  to  tumours  in  various 
regions.  The  former  have  a  very  elastic  feeling,  and  are  generally  somewhat  ten- 
der, or  rather,  one  might  say,  a  cause  of  aching  than  of  pain;  the  latter  are  hard 
very  constantly  tender,  and  often  inflamed :  they  ean  onlv  exist  in  the  situations 
in  which  anatomy  teaches  us  these  structures  are  to  be  found  in  health.  This 
forms  the  first  ground  for  diagnosis ;  and  in  regard  to  the  glands,  we  have  the 
further  knowledge  of  the  ordinary  causes  of  their  enlargement,— the  existence  of 
some  wound  of  skin  or  irritation  at  a  distance,  and  the  scrofulous  diathesis. 

Scrofulous  enlargements  are  much  more  frequent  in  the  neck  than  elsewhere. 
Difficulty  is  most  likely  to  be  experienced  in  deciding  whether  a  swelling  in  the 
groin  be  an  enlarged  gland  or  a  small  hernia.  The  history  will  verv  generally 
serve  to  clear  up  auy  doubt,  because  the  descent  of  a  hernia  is  sudden,"  commonly 
after  a  strain  or  muscular  effort,  and  if  it  continue  to  enlarge  it  soon  exceeds  the 
magnitude  of  a  gland.  In  addition  to  this,  a  hernia  mav  be  almost  always  pushed 
back,  and  protrudes  sensibly  on  forced  expiration  in  coughing.  Enlargement  of 
the  mammary  gland  is  another  form  of  superficial  tumour:  its  consideration  be- 
longs entirely  to  the  domain  of  surgery,  as  also  does  that  of  fatty  tumours. 

In  reviewing  the  various  regions,  we  find  on  the  scalp  encysted  tumours,  peri- 
osteal thickening,  and  fungoid  growth;  the  former  distinguished  by  their  not  beW 
adherent  to  the  bone,  the  latter  by  their  hardness  and  tenderness.  The  face  is 
especially  the  seat  of  epithelial  cancer.  In  the  neck  we  encounter  enlarged  glands 
both  lymphatics  already  mentioned,  and  salivary  glands,  which  will  be° noticed  in 
speaking  of  affections  of  the  mouth  and  throat.  We  also  find  occasionally  a  chro- 
nic enlargement  of  the  thyroid  gland,  in  the  form  of  goitre.     This  is  a  tumour 


116  DEPRAVED    CONSTITUTIONAL    STATES. 

soft  and  painless,  ami  generally  very  moveable,  extending  across  the  trachea,  be- 
low the  larynx,  commonly  more  to  one  side  than  the  other.  There  are  no  general 
symp  onnected  with  its  presence;  it  may  indicate  faulty  nutrition,  bat  the 

health  is  unimpaired,  and  it  is  more  a  matter  of  inconvenience  than  actual  dis- 
ease. 

The  region  of  the  neck  is  closely  connected  with  the  thoracic  cavity,  and  deep- 
Beated  tumours  there,  may  come  within  reach  of  the  finger  as  they  rise  in  the  neck. 
We  are  not  now  to  enter  upon  the  consideration  of  such  as  can  only  be  recognised 
by  auscultation ;  our  present  purpose  is  only  to  speak  of  those  which  are  superficial. 
Mention  has  already  been  made  of  tumours  upon  the  ribs,  and  inflammation  and 
suppuration  of  the  wall  of  the  chest.  Where  matter  has  already  formed,  a  soft 
tumour  is  found  on  the  surface  of  the  chest:  this  may  have  its  origin  in  a  local 
collection  of  pus  in  the  pleura  making  its  way  out.  The  history  of  internal  in- 
flammation and  superficial  abscess  is  in  general  different,  and  if  there  be  any 
doubt  on  the  subject,  recourse  must  be  had  to  the  evidence  which  the  stethoscope 
affords  of  the  state  of  the  lung  and  pleura. 

Aneurism  also  gives  rise  to  a  soft  tumour  when  it  reaches  the  surface,  but  this 
commonly  pulsates;  a  collection  of  pus  can  only  do  so  under  peculiar  circum- 
stances. The  pus  generally  tends  to  the  lower  part  of  the  chest,  aneurism  more 
frequently  shows  itself  at  the  upper.  In  both  cases  the  lungs  and  heart  must  each 
be  examined;  and  some  trace  of  disease  in  the  one  or  the  other  will  serve  to  de- 
termine us  whenever  there  is  any  obscurity  about  the  symptoms. 

A  firm  elastic  tumour  protruding  above  the  ribs,  is  generally  an  advanced  stage 
of  malignant  growth  in  the  chest.  It  is  associated  with  general  dulness  on  per- 
cussion either  on  one  or  both  sides,  and  with  indications  of  pressure  on  the  bron- 
chi, the  vessels,  and  the  nerves;  with  local  pains  in  the  arms,  local  oedema,  venous 
tortuosity,  occlusion  of  arteries,  &c.  These  symptoms  will  be  taken  in  detail  here- 
after. It  is  to  be  remembered  that  the  sallow  hue  of  malignant  disease  is  gene- 
rally obscured  by  the  obstruction  to  the  circulation. 

Fungoid  tumour,  attached  to  the  interior  of  the  ribs,  and  pressing  out  between 
them,  is  not  very  easily  distinguished  from  superficial  swelling.  It  very  often 
happens  that  the  patient  has  first  noticed  it  after  unusual  muscular  effort,  and  its 
progress  has  caused  such  infiltration  and  even  protrusion  of  the  parietes,  that  it  is 
liable  to  be  regarded  as  having  been  caused  by  the  strain,  and  to  consist  merely 
of  an  effusion  of  blood  under  the  muscles.  When  close  to  the  sternum,  its  cha- 
racters are  more  palpable,  as  a  rounded,  firm,  and  elastic  swelling;  it  has  not  the 
softness  of  a  collection  of  fluid,  but  it  may  pulsate,  from  its  proximity  to  the  heart. 
After  a  time  the  cachexia  of  cancer,  or  the  appearance  of  a  second  tumour,  may 
remove  all  doubts. 

In  thoracic  tumours  recourse  may  sometimes  be  had  to  the  introduction  of  a 
grooved  needle.  It  must  be  admitted  that  this  is  only  a  refuge  for  ignorance;  but 
ignorance  is  sometimes  unavoidable  .in  such  obscure  cases. 

In  the  abdomen,  a  tumour  may  be  simulated  by  mere  muscular  resistance. 
Knotted  contraction  of  the  rectus,  or  even  of  some  portions  of  the  transverse  mus- 
cles, may  give  rise  to  doubt ;  some  patients  cannot  be  brought,  by  any  inducement, 
perfectly  to  relax  the  muscles,  not  only  from  unwillingness,  but  from  some  abdo- 
minal irritation.  This  feeling  of  hardness  is  less  local  than  tumour;  it  is  also  per- 
ceived to  move  with  the  parietes,  and  cannot  be  pushed  aside.  A  jerking  move- 
ment with  the  tips  of  the  fingers  in  making  pressure  over  different  parts,  will  often 
serve  to  determine  whether  there  be  any  hardness  behind  the  abdominal  walls;  or 
by  slow,  firm  pressure,  we  may  overcome  the  parietal  resistance.  It  is  also  im- 
portant to  ascertain  whether  there  be  dulness,  on  percussion,  over  the  part,  where 
the  existence  of  a  tumour  is  suspected. 

When  a  tumour  is  made  out,  its  relation  to  the  abdominal  viscera  must  next  be 
considered:  if  small,  its  present  position;  if  of  some  size,  its  point  of  origin.  But 
patients  very  often  give  the  most  extraordinarily  inconsistent  accounts  of  the  ori- 
gin of  these  growths. 

In  the  right  hypochondrium  it  is  probably  connected  with  the  liver,  and  the 
symptoms  of  disease  of  this  viscus  must  be  studied.  It  may  be  simply  enlarged, 
from  congestion  or  inflammation;  or  from  chronic  disease;  or  it  may  be  displaced 


MORBID    GROWTHS.  117 

from  the  pressure  of  a  belt  in  men  or  of  tightly-laced  stays  in  women.  Under  such 
circumstances,  the  edge  of  the  liver  of  nearly  its  natural  form  may  be  felt,  some 
way  below  the  margins  of  the  ribs,  with  firm  resistance  above  and  duluess  on  per- 
cussion. Sometimes  on  the  surface  of  this  enlarged  mass  a  rounded  fulness  is  ob- 
served, giving  a  sense  of  obscure  fluctuation.  It  is  important  to  distinguish  that 
it  is  on  the  surface,  and  not  at  the  edge,  where  a  distended  gall-bladder  may  be 
felt  in  the  same  way.  If  the  history  and  symptoms  are  those  of  acute  disease,  this 
will  indicate  suppuration;  if  they  are  chronic,  it  is  more  probably  due  tr>  the  pre- 
sence of  hydatid  cysts.  In  place  of  the  regular  form  of  an  enlarged  liver,  several 
rounded  masses  may  be  felt  in  this  region,  extending  more  or  less  across  the  epi- 
gastrium. This  is  undoubtedly  malignant,  and  the  diagnosis  of  its  connexion  with 
the  liver  depends  both  on  the  general  symptoms  of  disease  of  that  organ,  and  on 
the  circumstance  that,  by  percussion  and  palpation,  it  is  ascertained  that  they  are 
continuous  with  it.  This  point  must  always  be  thoroughly  investigated,  because, 
of  necessity,  when  enlarged,  it  extends  into  the  epigastrium,  as  it  is  limited  by  the 
ribs  in  the  opposite  direction. 

One  or  even  more  hard  masses  in  the  centre  of  the  epigastrium,  or  lower  down 
towards  the  umbilicus,  not  connected  with  the  liver,  are  most  commonly  caused 
by  cancer  of  the  stomach.  The  general  symptoms  are  more  especially  referrible 
to  that  organ,  and  there  is  almost  always  vomiting,  which  at  one  period  or  other 
has  been  grumous  or  like  "coffee  grounds."  The  sallow,  anaemic  hue  of  malig- 
nant disease  is  especially  marked,  from  the  combination  of  cancerous  growth  and 
mal-nutrition. 

In  the  left  hypochondrium,  simple  enlargement  of  the  spleen  produces  a  tumour 
of  an  oval  figure,  which  is  perfectly  even  on  the  surface.  This  mass  has  some- 
times been  of  such  size  as  to  reach  quite  down  into  the  right  iliac  fossa.  Its  at- 
tachment is  in  the  left  hypochondrium,  and  the  diagnosis  will  be  more  or  less  cer- 
tain, as  this  fact  can  be  made  out. 

Occasionally  a  firm,  hard  tumour  may  be  felt  to  the  left  of  the  epigastrium, 
which  cannot  be  traced  into  the  hypochondrium,  and  which,  though  accompanied 
by  mal-nutrition,  has  not  been  associated  with  symptoms  distinctly  traceable  to 
disease  of  the  stomach;  such  tumours  have  been  found  after  death  to  be  owing  to 
scirrhus  of  the  pancreas.  The  diagnosis  is  very  difficult,  and  the  position  of  the 
stomach  is  often  such  as  to  render  it  impossible  to  feel  the  hardened  mass  during 
life. 

In  the  lower  part  of  the  abdomen  in  females  the  conditions  of  the  organs  of  ge- 
neration, the  uterus,  aud  ovaries  must  be  considered:  these  will  be  discussed  in 
their  proper  place.  Tumours  connected  with  these  organs  all  spring  out  of  the 
pelvis.  In  the  right  iliac  region  accumulations  of  fasces  may  simulate  a  tumour: 
this,  though  their  most  common,  is  not  their  only  locality;  and  I  would  take  the 
opportunity  of  reminding  my  younger  readers  that,  in  all  examinations  of  the  ab- 
domen, care  should  be  taken  to  obtain  a  full  and  free  evacuation  of  the  bowels 
before  a  diagnosis  be  pronounced.  Similarly,  in  the  centre  of  the  hypogastrium, 
a  hard,  round  tumour  may  be  discovered,  simply  due  to  over-distentiou  of  the 
bladder.  By  careful  manipulation,  fluctuation  can  be  discovered;  but  here,  too, 
caution  must  be  exercised,  and,  in  cases  of  doubt,  a  catheter  should  be  introduced, 
to  ascertain  its  exact  condition. 

Tumours  below  the  level  of  the  umbilicus,  not  traceable  to  these  causes,  gene- 
rally have  their  origin  in  diseased  conditions  of  the  omentum,  or  of  the  lymphatic 
glands  of  the  abdomen,  or  in  local  peritonitis.  The  two  former  present  more  de- 
cided characters  of  tumour,  defined  and  indurated;  the  latter  is  more  diffuse,  and 
very  generally  adherent  to  the  parietes.  They  differ,  too,  in  their  history,  as  peri- 
tonitis is  associated  with  pain  and  febrile  disturbance,  which  are  not  essential  to 
the  others;  and  while  the  disease  lasts,  the  symptoms  are  those  of  a  partially  acute 
disorder.  It  very  often  terminates  in  abscess ;  it  may  be  caused  by  a  blow,  or  by 
inflammation  or  ulceration  of  some  part  of  the  bowel.  In  females,  it  may  be  con- 
fined to  the  structures  round  the  uterus,  and  is  best  distinguished  from  the  specific 
diseases  of  the  generative  organs,  by  their  having  become  adherent  to  the  sur- 
rounding parts,  by  the  undefined  character  of  the  swelling  itself,  and  by  its  ten- 
derness on  pressure. 


US  DEPRAVED    CONSTITUTIONAL    STATES. 

Disease  of  the  omentum  comes  on  gradually;  it  may  be  associated  with  irregu- 
larity of  the  bowels,  sometimes  marked  by  constipation,  and  not  unfrequently  by 
some  form  of  hemorrhage,  but  not  attended  with  fever.  The  general  state  of  the 
nt  is  ana-mic  and  cachectic:  the  tumour  itself  is  generally  hard,  and  often 
nodulated,  and  may  be  made  to  move  by  turning  the  patient  in  bed  from  oue  side 
to  the  other.     It  often  gives  rise  to  pain,  but  is  not  essentially  tender. 

Disease  of  the  glands  very  generally  causes  oedema  of  the  feet  and  legs;  and 
sometimes  also  ascites,  which  much  obscures  its  diagnosis:  in  this  case,  its  cha- 
racters are  ill-defined,  but  the  tumour  is  generally  found  firmly  fixed,  and  deeply 
seated  towards  the  spine. 

Tumours  in  the  abdomen  are  very  liable  to  pulsate;  and  the  question  will  occur, 
whether  it  be  aneurism.  Abdominal  pulsation  is  of  comparatively  little  value,  be- 
cause all  the  contents  of  the  abdomen,  lying  as  they  do  above  the  aorta  and  great 
vessels,  are  liable  to  succussion  at  each  systole  of  the  heart ;  neither  is  the  pre- 
sence of  a  "bruit"  to  be  too  much  regarded,  because,  even  in  health,  considerable 
pressure,  and,  in  anaemic  states,  very  slight  pressure  on  a  large  vessel,  is  suilicient 
for  its  production.  Enlargements  of  the  liver  and  spleen  are  least  likely  to  simu- 
late aneurism.     (For  further  particulars  the  reader  is  referred  to  Chap.  XXIII.) 

§  3.  Of  the  Characters  of  Tumours. — After  what  has  been  said 
upon  the  localization  of  tumours,  there  is  little  to  add  on  the  sub- 
ject of  their  discrimination,  as  that  can  only  he  dealt  with  on  cer- 
tain broad  principles,  when  internal  organs  are  concerned.  To  the 
surgeon  it  is  all-important  to  be  able  to  determine  whether  an 
external  tumour  belong  to  the  class  of  malignant  or  non-malig- 
nant disease;  whether  the  condition  of  the  patient  be  such  as  to 
lead  him  to  recommend  its  removal  with  the  knife,  or  to  abstain 
from  so  doing ;  or  whether  the  character  of  the  tumour  be  such  as 
gives  him  ground  to  hope  for  its  diminution  or  disappearance  by 
the  employment  of  remedies  of  a  less  formidable  character.  To 
him,  however,  the  question  involves  a  great  deal  more  than  the 
consideration  of  the  mere  palpable  characters  of  the  tumour;  he, 
too,  has  to  consider  its  history,  its  mode  of  growth,  and  its  effects, 
as  well  as  the  condition  of  his  patient,  both  with  reference  to  cir- 
cumstances connected  with  his  previous  life  and  his  present  state. 
To  the  physician  these  are  the  questions  of  real  moment:  many 
anomalous  conditions  are  found  after  death  which  had,  and  could 
have  no  history  during  life;  many  which,  while  offering  few  analo- 
gies to  the  post-mortem  inquirer,  have  histories  scarcely  distin- 
guishable the  one  from  the  other ;  while,  again,  many  of  which  the 
histories  differ  present  lesions  closely  corresponding. 

The  knowledge  of  these  difficulties  must  not  deter  us  from 
making  the  inquiry,  so  far  as  practicable,  into  the  exact  nature  of 
the  disease ;  but  it  ought  to  lead  us  to  embrace  in  our  view  the 
whole  of  the  circumstances  of  each  individual  case.  To  these  we 
especially  look  for  guidance  in  determining  the  very  important 
question,  whether  we  have  to  do  with  the  results  of  inflammation, 
or  with  a  true  or  false  hypertrophy  of  the  organ,  or  with  a  malig- 
nant and  necessarily  fatal  disease;  and  we  must  place  in  a  subor- 
dinate rank  the  suggestions  that  may  be  received  from  the  locality 
or  the  sensible  qualities  of  the  tumour. 

The  forms  which  have  been  admitted  into  the  table  as  being  met 


CHARACTERS    OF    TUMOURS.  119 

■with  in  the  medical  -wards  of  the  hospital  are :  (a)  cystic  growths, 
(b)  fungoid  or  encephaloid  cancer,  (c)  scirrhus,  (d)  colloid  cancer, 
(e)  growths  from  bone. 

a.  In  considering  the  relative  frequency  with  which  we  encounter 
these  several  forms  of  morbid  growth  in  different  regions  or  organs, 
it  may  be  remarked  that  cystic  growths  divide  themselves  into  two 
classes,  the  acephalo-cyst,  which  is  entirely  adventitious,  and  the 
simple  or  compound  cyst,  which  consists  of  an  abnormal  develop- 
ment of  natural  structure.  We  have  already  referred  to  the  con- 
nexion between  the  acephalo-cyst,  or  simple  hydatid,  and  the 
echino-coccus ;  practically  there  is  no  advantage  in  discriminating 
cystic  growths  except  in  so  far  as  the  knowledge  of  the  presence  of 
fluid  derived  from  its  fluctuation  leads  to  the  evacuation  of  the  con- 
tents. They  all  have  this  property  in  common,  that  their  destruc- 
tive tendency  is  limited  to  the  organ  in  which  they  are  situated, 
and  they  affect  the  general  health  no  further  than  as  the  function 
of  that  organ  is  of  importance,  or  their  size  interferes  with  the  in- 
tegrity and  usefulness  of  surrounding  structures.  The  hydatid  is 
especially  prone  to  infest  the  liver ;  and  there  it  is  alone  that  its 
presence  can  be  made  out  with  the  remotest  degree  of  confidence 
during  life:  of  the  other  forms  of  cyst  those  only  claim  any  notice 
which  are  found  in  the  mammae  and  in  the  ovaries.  Pathological 
anatomy,  indeed,  teaches  us  that  other  organs  are  liable  to  become 
the  site  of  cystic  growth,  but  I  know  of  no  test  by  which  they  can 
be  brought  under  the  province  of  diagnosis. 

b.  Fungoid  or  encephaloid  cancer  is  the  form  of  malignant  dis- 
ease commonly  found  in  the  chest,  whether  it  be  attached  to  the 
pleura  or  the  mediastinum  (in  both  of  which  it  is  sometimes  a  mat- 
ter of  doubt  whether  its  first  point  of  departure  be  not  from  bone,) 
or  whether  it  be  developed  from  the  intra-thoracic  glands,  or,  as 
happens  in  rare  instances,  from  the  glands  in  the  axilla.  In  the 
abdomen,  it  is  the  character  which  cancerous  growth  generally  pre- 
sents in  the  liver,  it  is  that  which  is  always  developed  when  its  ori- 
gin is  in  the  deep-seated  lumbar  glands,  and  it  forms  the  most 
numerous  section  of  cancers  of  the  uterus  and  vagina. 

c.  Scirrhus,  again,  exists  in  the  largest  proportion  of  cases  of 
cancer  of  the  stomach;  it  attacks  the  rectum,  and  in  rarer  cases, 
other  portions  of  the  alimentary  canal :  in  all  of  these  we  rest  our 
diagnosis  chiefly  on  that  which  is  known  to  be  its  constant  result, 
partial  occlusion  of  the  passage,  which  is  not  unfrequently  com- 
bined w7ith  subsequent  ulceration ;  evidence  proving  this  event  is 
therefore  very  confirmatory.  Scirrhus  of  the  uterus  and  vagina 
are  often  spoken  of,  and  no  doubt  exist  in  many  instances:  most 
commonly,  however,  it  is  combined  with  fungoid  disease,  and  very 
often  cases  are  called  scirrhus  which  ought  to  be  called  fungus. 

d.  Colloid  cancer  seems  most  readily  developed  in  the  loose 
structure  of  the  omentum  and  of  the  peritoneum  generally;  and 
its  existence  can  only  be  inferred  from  the  fact  of  abdominal  en- 


120  DEPRAVED   CONSTITUTIONAL    STATES. 

largement,  which  cannot  otherwise  be  accounted  for,  coinciding 
with  constitutional  disturbance.  This  form  of  cancer,  however,  is 
the  one  in  which  cachexia  is  least  marked;  and  I  must  again  repeat 
that  that  is  the  most  important  point  in  medical  diagnosis  when  wc 
speak  of  cancer.  It  is  at  least  unwise  to  give  an  opinion  implying 
the  existence  of  cancer  when  the  general  indications  do  not  point 
to  something  more  than  can  be  traced  to  local  disorder;  and  while 
it  is  quite  true  that  all  internal  growths  are  of  serious  import, 
because  they  are  so  little  amenable  to  treatment,  we  must  exercise 
great  caution  in  attempting  to  analyze  further,  and  say  what  is  the 
exact  character  of  the  growth. 

e.  Growths  from  bone  seldom  come  under  the  physician's  notice, 
except  when  developed  in  the  mediastinum,  on  the  ribs,  or  on  the 
bones  of  the  pelvis:  in  these  localities  they  are  usually  of  a  malig- 
nant character;  the  slower  growing  enchondroma  is  less  common 
in  them  than  in  the  long  bones  of  the  extremities,  and  the  same  is 
true  of  the  myeloid  growths  which  have  of  late  occupied  the 
attention  of  surgeons. 

In  history  and  physical  characters,  each  of  these  forms  of  tumour 
presents  differences  which  aid  in  their  discrimination.  Those  con- 
nected with  the  ovaries  will  be  discussed  in  a  future  chapter;  and 
in  speaking  of  the  female  generative  organs,  we  shall  have  to  treat 
of  growths  peculiar  to  the  uterus,  which  are  not  here  alluded  to, 
because  of  their  invariable  local  connexion.  (See  Chaps.  XXXII. 
and  XXXIII.)  The  diagnosis  of  cystic  diseases  of  the  mammas  is 
essentially  a  question  of  surgery.  Serous  cysts  in  internal  organs 
are  distinguished  by  their  even,  rounded  surface,  and  the  sense  of 
fluctuation  given  to  the  finger  of  the  observer;  from  their  history 
we  learn  that  the  development  has  been  slow,  while  the  condition 
of  the  patient  proves  that  health  is  only  interfered  with  so  far  as 
pressure  impedes  circulation,  nutrition,  or  secretion.  Encephaloid 
cancer  is  also  rounded;  but  its  surface  is  seldom  even,  it  is  nodu- 
lated and  irregular,  firm  and  elastic  to  the  touch.  Its  history  is  of 
decidedly  rapid  growth,  though  it  varies  much  in  this  respect;  the 
patient  suffers  not  only  from  the  destruction  of  the  organ  which  it 
affects,  and  the  evils  arising  from  interrupted  function,  but  also 
labours  under  a  cachexia  which  infects  his  whole  system.  Scirrhus 
feels  very  hard,  and  presents  only  one  or  two  distinct  nodules  with 
more  or  less  irregularity  of  surface.  Its  progress  is  slow;  its 
history  details  disordered  function  long  before  any  tumour  has  been 
noticed,  and  the  cachexia  of  the  patient  derives  increased  intensity, 
from  the  interference  with  due  nutrition,  when  the  disease  is  situated 
in  the  alimentary  canal ;  pain  is  more  constantly  present  in  this 
than  in  any  other  morbid  growth.  Colloid  cancer  presents  an 
unevenly  rounded,  highly  elastic  surface;  it  may  give  a  sensation 
to  the  ringer  nearly  akin  to  fluctuation;  the  secondary  nodules, 
which  would  serve  very  often  as  a  pretty  certain  index  of  its  nature, 
cannot  be  detected  during  life.     Its  growth  is  rapid;  it  does  not 


CHARACTERS    OF    TUMOURS.  121 

greatly  impregnate  the  system  at  large,  but  its  position  is  such  as 
commonly  interferes  very  considerably  with  the  assimilative  process. 
The  malignant  growths  from  bone  belong  to  the  more  rapid-growing 
cancers,  although  generally  firm  and  inelastic.  This  fact  in  their 
history  serves  to  distinguish  them  from  the  non-malignant  osseous 
growths,  but  their  diagnosis  need  not  go  much  beyond  the  question 
of  the  real  or  simulated  connexion  with  bony  structure;  this  is 
proved  by  their  immobility  and  position.  They  take  more  or  less 
the  direction  of  the  bone  to  which  they  are  attached,  and  while 
some  degree  of  movement  can  be  made  out  between  the  superficial 
structure  and  the  tumour,  none  can  be  obtained  by  any  manipula- 
tion between  that  and  the  bone. 

Enlarged  synovial  bursas  and  fatty  tumours  are  recognised  by 
their  general  indolent  character,  their  locality,  and  the  sense  of 
fluctuation  and  elasticity  which  each  presents. 


122 


CHAPTER  X. 

THE   QUASI-NERVOUS   DISEASES. 

§  1,  Hysteria — Evidence  almost  entirely  negative — Simulation  of 
other  Diseases — §  2,  Chorea  and  Tetanus — The  Muscular  Symp- 
tom in  each — Causes  and  Associations — §  3,  Delirium  Tremens 
— Condition  of  Patient — Alliance  to  Mental  Disease. 

§  1.  Hysteria. — The  important  distinction  we  have  drawn  be- 
tween objective  and  subjective  phenomena,  derives  its  fullest  illus- 
tration from  this  protean  malady.  Here  the  sensations  of  pain  and 
uneasiness  are  out  of  all  due  proportion  to  the  derangement  of 
function  and  of  nutrition ;  the  feelings  of  the  patient  are  the  all- 
absorbing  idea  in  her  mind,  and  so  completely  do  they  take  posses- 
sion of  her  faculties,  of  her  very  nature,  that  vital  functions  over 
which  she  has  really  no  voluntary  control,  are  swayed  by  the  force 
which  these  feelings  exercise  when  they  become  concentrated  on 
any  particular  organ.  Although  most  fully  developed  in  the  female 
sex,  and  originally  deriving  its  name  from  a  supposed  excitement 
of  the  female  generative  organs,  an  analogous  disease  is  not  unfre- 
quently  seen  in  men  exhausted  from  any  debilitating  cause,  or 
effeminate  from  over-care  and  nursing  of  themselves;  extreme 
nervousness  is  the  only  term  in  common  use  to  express  such  a  state. 
There  is  no  exact  line  of  demarkation  between  this  condition  and 
one  in  which,  the  attention  becoming  fixed  on  some  particular  organ, 
sensations  are  supposed  to  arise  there,  of  the  non-existence  of  which 
we  are  satisfied  by  collateral  evidence  of  their  absurdity  or  impos- 
sibility: to  this  the  name  of  hypochondriasis  has  been  applied;  it 
merges  into  insanity. 

The  question  of  diagnosis  then  simply  takes  the  form  of  an 
inquiry  into  the  reality  and  importance  of  the  complaints  of  the 
patient.  When  these  stand  alone,  or  are  out  of  due  proportion  to 
other  evidence  of  disease,  we  conclude  that  they  are  exaggerated, 
if  not  unreal;  and  when  their  intensity,  as  described  in  language, 
is  not  borne  out  by  the  actual  effect  upon  the  individual,  we  conclude 
that  they  are  unimportant.  The  following  remarks  will  apply  to 
either  sex,  although  especial  reference  must  be  had  to  the  female 
in  discussing  the  subject  of  hysteria.  There  is  usually  such  a  con- 
stant simulation  of  other  diseases,  that  it  is  impossible  to  draw  any 
general  picture  of  it  which  would  apply  to  every  case,  the  only 
feature  which  they  have  in  common,  being  the  negative  one  of  the 
absence  of  some  important  indication  which  is  absolutely  essential 
to  the  existence  of  the  reality  which  is  imitated  by  it:  the  function 
which  ought  to  be  deranged  is  unchanged;  the  sign  or  the  symptom 


HYSTERIA.  123 

which  ought  to  be  found  is  'wanting;  or  we  may  even  obtain  direct 
evidence  that  the  organ  which  is  supposed  to  be  the  seat  of  disease 
is  in  a  perfectly  natural  and  normal  condition,  except  that  it  is  the 
point  on  which  those  morbid  sympathies  are  concentrated. 

It  has  been  already  pointed  out,  how  impossible  it  is  to  form  any 
standard  of  comparison  by  which  to  measure  expressions  of  pain. 
Other  sensations  admit  of  more  analysis,  and  generally  have  a  more 
definite  range.  Thus  a  sensation  of  numbness  may  be  analyzed 
into  actual  deficiency  of  sensitive  power,  or  into  mere  tingling, 
which  produces  a  relative  feeling  of  insensibility:  a  sensation  of 
weight,  whether  in  the  head  or  at  the  epigastrium,  is  an  explicit 
statement  of  what  we  can  understand,  and  what  we  can  generally 
refer  to  some  co-existing  morbid  state.  Of  pain  generally  it  is 
most  important  to  remember  that  it  does  not  imply  inflammation: 
too  frequently  these  words  are  regarded  as  almost  synonymous,  and 
complaint  of  severe  pain  calls  forth  all  the  energies  of  anti-phlogistic 
treatment:  it  is  in  reality  nothing  more  than  an  expression  of  irri- 
tation of  some  nerve,  and  the  cause  of  that  irritation  is  to  be 
sought  for. 

The  history  often  throws  great  light  upon  the  nature  of  the  case. 
Disorder  of  the  uterine  functions,  often,  very  often,  acts  upon  the 
imagination  of  the  patient,  leading  her  to  pay  attention  to  and 
exaggerate  slight  uneasy  sensations.  Long  ailment  without  mate- 
rial loss  of  flesh,  proves  that  the  sensations  are  not  indicative  of 
serious  disease.  The  commencement  of  the  present  attack  has  not 
been  ushered  in  by  the  usual  accompaniments  of  an  acute  or  febrile 
disorder;  in  place  of  rigor  or  flushing,  there  has  perhaps  been  a 
fainting  fit,  or  an  hysterical  paroxysm,  and  the  whole  relation  of 
symptoms  betrays  more  or  less  of  inconsistency  in  their  sequence 
and  their  supposed  causes  and  effects. 

At  the  time  of  examination  the  pulse  may  be  either  quiet  or 
temporarily  excited  and  quick,  without  heat  or  dryness  of  skin ;  it 
is  not  hard  or  wiry,  it  is  not  firm  nor  is  it  often  full,  but  generally 
weak,  and  varying  with  the  least  excitement.  If  the  face  be 
flushed,  it  is  out  of  proportion  to  the  condition  of  the  rest  of  the 
skin.  The  tongue  may  be  evenly  coated,  with  projecting  red  pa- 
pilloe ;  but  there  is  no  red  edge,  no  thick  brown  streak  in  the  centre, 
nor  any  patchy  abrasion  of  epithelium ;  it  is  not  dry,  nor  is  there 
accompanying  thirst.  The  urine  is  pale,  limpid,  and  copious;  the 
bowels  not  altered  from  their  usual  state.  There  is  no  marked 
emaciation ;  there  is  no  pinching  nor  anxiety  of  features;  sometimes 
a  marked  readiness  to  tears,  or  alternation  from  smiles  to  frowns. 

There  is  often  alleged  loss  of  power,  in  one  or  both  legs,  or  in 
one  arm.  The  best  evidence  of  the  reality  of  this  state  is  obtained 
by  rather  rough  handling,  which  will  always  bring  out  resistance; 
but  it  must  be  remembered  that  real  loss  of  power  is  sometimes 
associated  with  spasm  or  reflex  action,  and  to  complete  the  evidence 
the  limb  should  be  placed  in  a  constrained  position,  while  the 


12-1  THE    QUA  SI- NERVOUS    DISEASES. 

attention  of  the  patient  is  strongly  directed  to  some  other  organ; 
if  the  mind  be  thoroughly  pre-occupied,  it  will  be  supported  for  a 
moment    or  two  by  voluntary  effort. 

On  examining  the  region  to  which  pain  is  referred,  we  very  gene- 
rally find  extreme  tenderness;  the  slightest  touch  is  represented  as 
very  painful,  much  more  so  than  anything  short  of  the  most  intense 
cutaneous  inflammation  could  account  for  ;  it  is  diffused  over  a  large 
surface,  and  is  not  local  or  limited;  and  if  the  attention  can  be 
abstracted,  very  firm  pressure  is  borne  without  apparent  increase 
of  suffering.  Very  good  evidence  of  this  fact  may  be  obtained  by 
varying  the  tactile  manipulation  with  one  hand  and  directing  the 
patient's  attention  to  that,  while  firm  pressure  is  made  with  the 
other,  or  by  referring  to  the  condition  of  the  uterine  or  any  other 
functions  in  which  the  patient  feels  especially  interested.    • 

In  females  the  globus  hystericus,  or  rising  in  the  throat,  or  the 
occurrence  of  a  regular  hysterical  paroxysm,  often  materially  aids 
the  diagnosis.  But  all  the  ordinary  evidences  of  hysteria  must  not 
cause  us  to  forget  the  possible  co-existence  of  some  severe  ailment 
in  such  a  constitution ;  and  this  so  much  the  more  that  the  very 
exaggeration  of  the  symptoms  may  lead  us  to  doubt  the  existence 
of  actual  disease  in  its  early  stage,  when  practical  experience 
teaches  us  that  it  is  not  necessarily  associated  with  such  symptoms. 
It  is  often  a  very  nice  point  to  determine  what  is  due  to  imagina- 
tion— perhaps  associated  with  perverted  volition, — what  is  simply 
due  to  exaggeration,  and  what  there  is  of  real  disease  in  the  condi- 
tion of  the  patient;  and  this  can  only  be  done  by  carefully  weigh- 
ing the  relation  of  disordered  sensations,  of  perverted  functions,  and 
of  abnormal  or  normal  physical  signs  in  each  organ  in  succession. 

As  the  more  frequent  forms  of  hysteria  are  mere  simulations  of 
severe  disease,  so  a  regular  hysterical  paroxysm  is,  after  its  fashion, 
a  simulation  of  epilepsy.  The  limbs  are  tossed  about  with  the 
same  violence,  but  more  of  method  may  be  detected  in  the  hyste- 
rical, more  of  regularity  in  the  epileptic  convulsions.  The  patient 
in  epilepsy  bites  his  tongue  severely,  hurts  or  wounds  himself  in 
falling ;  the  hysterical  female  never  seriously  injures  herself,  and  is 
only  bruised  by  the  energy  of  her  movements  during  the  paroxysm. 
The  expression  of  the  features  is  often  horribly  distorted  in  epilepsy; 
is  generally  placid  in  hysteria,  with  a  quivering  tremulous  move- 
ment of  the  closed  eyelids.  The  epileptic  fit  ends  in  deep  slumber, 
the  hysterical  paroxysm  often  in  tears :  in  the  one  consciousness  is 
suspended,  in  the  other  it  is  not  so,  except  when  fainting  occurs; 
but  of  this  it  is  sometimes  extremely  difficult  to  feel  quite  certain. 

§  2.  Chorea  and  Tetanus. — This  is  perhaps  the  best  place  to 
notice  two  diseases  which  stand  on  the  confines  of  general  disorder 
of  the  whole  system,  and  special  derangement  of  the  nervous  element 
in  it.  They  are  marked  by  striking  objective  phenomena,  which 
consist  of  acts  of  the  muscular  system  not  only  involuntary,  but 


CHOREA    AND   TETANUS.  125 

uncontrollable.  These  acts  may  be  associated  'with,  a  variety  of 
other  symptoms,  as  they  may  be  with  differing  conditions  of  in- 
ternal organs ;  but  the  muscular  movement  stands  by  itself  as  the 
sole  indication  by  which  the  disease  is  recognised.  Here  diagnosis 
has  but  little  to  do.  The  element  of  the  disease  is  quite  unknown 
to  us,  and  hence  it  is  to  the  prominent  symptom  alone  that  we  have 
as  yet  to  look  for  the  discrimination  of  each;  to  this  symptom  the 
name  of  the  disease  is  applied,  and  by  this  is  it  characterized. 

The  movements  of  chorea  once  seen  can  never  be  forgotten  or 
mistaken ;  nor  can  the  fearful  spasms  of  tetanus  be  taken  for  any- 
thing else.  It  is  true  that  in  severe  lesions  of  the  brain,  when  the 
patient  is  in  a  state  of  stupor,  or  of  delirium,  convulsive  movements 
may  be  seen  in  some  cases,  spasms  of  muscles  in  others;  but  no  one 
who  has  seen  the  diseases  can  ever  mistake  them  for  chorea  or  tetanus. 

It  is  quite  foreign  to  the  purpose  of  this  work  to  draw  pictures  of  disease,  as 
our  sole  consideration  is  the  gronnd  upon  which  diagnosis  is  to  be  formed.  In 
chorea  we  rely  upon  the  restless  jactitation,  the  tossing  hither  and  thither  in  the 
most  uncertain  manner  of  one  or  more  limbs,  or  of  the  whole  body.  In  tetanus, 
on  sudden  and  violent  contraction  of  various  sets  of  muscles,  frequently  alter- 
nating with  as  sudden  relaxation.  In  chorea  the  system  at  large  does  not  suffer 
much  disturbance,  except  when  other  conditions  of  disease  are  associated  with 
it:  in  its  more  severe  forms  the  expression  of  the  features  is  almost  maniacal, 
and  the  patient  becomes  gradually  exhausted  from  constant  restlessness,  inability 
to  take  food,  and  imsomnia,  terminating  in  delirium,  coma,  and  death.  In  te- 
tanus the  system  early  indicates  febrile  disturbance  of  a  low  and  adynamic  charac- 
ter, and  the  disease  is  generally  attended  by  rapid  sinking  and  prostration.  The 
spasm  of  tetanus  is  called  clonic,  from  its  sudden  invasion,  alternating  with  relaxa- 
tion: it  can  scarcely  be  confounded  with  tonic  spasm  or  perpetual  contraction  of 
particular  muscles,  which  is  constantly  associated  with  organic  diseases  of  the 
nervous  centres,  especially  with  certain  forms  of  pressure  and  with  induration  of 
the  brain  or  cord. 

Both  chorea  and  tetanus  maybe  simulated  by  hysteria;  but  the  imitation  is 
not  such  as  can  impose  upon  any  one  who  has  observed  the  true  disease  and  is 
prepared  for  such  a  simulation.  In  hysterical  movements  there  is  necessarily 
more  method  than  in  those  of  chorea;  in  hysterical  spasm  there  is  seldom  the 
exact  correspondence  in  the  condition  of  a  whole  set  of  muscles  found  in  true 
tetanus.  In  either  case,  when  the  suspicion  is  awakened,  the  abstraction  of 
the  patient's  attention  will  serve  to  interrupt  the  movements  or  relax  the  spasm. 

These  diseases  are  generally  found  associated  with  some  cause  of  irritation;  it 
may  be  said,  perhaps,  that  they  are  always  so,  although  our  means  of  analysis 
frequently  fail  to  detect  it.  In  chorea  we  have  to  seek  for  some  shock  to  the 
nervous  system  in  sudden  fright,  or  some  irritation  in  the  digestive  system ;  loaded 
bowels,  worms,  &c:  sometimes  the  vascular  system  is  deranged,  and  there  may 
be  a  condition  of  anasinia  or  disease  of  the  heart;  not  unfrequently  it  is  asso- 
ciated with  that  peculiar  condition  of  blood  that  manifests  itself  in  rheumatism ; 
sometimes  there  is  disease  in  the  nervous  system,  but  it  has  been  less  uniformly 
traced  to  this  than  to  the  other  conditions  already  enumerated. 

In  tetanus  we  inquire  whether  it  be  dependent  on  the  irritation  of  some  par- 
ticular nerve,  or  on  some  obscure  affection  of  the  brain  or  spinal  cord;  whether 
it  be  eccentric  or  centric;  traumatic,  from  the  irritation  of  a  wound,  or  idiopathic, 
without  known  cause:  in  the  latter  case  the  question  whether  it  have  arisen  from 
the  administration  of  poison  is  suggested  by  the  fearful  revelations  of  recent 
times.     Our  investigations  can  reach  no  further. 


o" 


§  3.  Delirium  Tremens. — We  must  also  class  this  as  a  disease 
which  involves  something  more  than  mere  disorder  of  the  nervous 
centres.     It  seems  to  be  due  to  perverted  nutrition  of  the  brain 


12G  THE   QUASI-NERVOUS   DISEASES. 

consequent  on  the  circulation  through  its  mass  of  impure  blood 
unsuited  to  develop  healthy  functions.  Its  relation  to  the  nervous 
system  is  somewhat  similar  to  that  of  mania :  in  classification  nei- 
ther of  them  can  be  regarded  as  diseases  of  the  nervous  system, 
because  in  each  there  is  an  element  extraneous  to  it ;  but  in  their 
development  they  are  so  intimately  associated  with  it  that  we  cannot 
doubt  that  they  are  accompanied  by  hidden  change  of  structure. 
"With  reference  to  diagnosis,  it  will  be  more  convenient  to  consider 
this  disease,  when  speaking  of  delirium  as  a  symptom  of  the  con- 
dition of  the  brain,  where  its  relations  to  other  forms  of  delirium 
will  be  more  easily  exhibited.  But  there  are  certain  general  ob- 
jective phenomena  by  which  it  is  marked;  it  is  a  delirium  cum 
trcmore.  Tremor  is  its  essential  characteristic,  which  every  act  of 
the  patient  betrays:  the  hand  cannot  be  held  still;  but  there  is 
neither  the  jactitation  of  chorea,  nor  the  regular  shake  of  paralysis 
agitans ;  the  tongue  quivers  when  protruded ;  and  these  movements 
dTffcr  from  the  ordinary  tremulousness  of  pure  nervous  debility,  in 
the  rapidity  and  excitement  with  which  each  act  is  performed.  The 
patient  sits  down  and  gets  up  in  a  hurry,  he  raises  himself  in  bed 
with  a  spring,  he  turns  suddenly  round  to  the  person  who  addresses 
him,  he  thrusts  forward  his  hand  for  the  pulse  to  be  felt,  and  he 
puts  out  his  tongue  with  the  same  quick  unsteady  movement,  when 
directed  to  do  so. 

All  this  may  occur  before  any  delirium  has  showed  itself.  From 
the  patient  himself,  or  his  friends,  it  will  be  learned  that  he  has 
either  lately  had  a  drinking  bout,  or  that,  being  an  habitual  drunk- 
ard, he  has  been,  under  circumstances  of  privation,  debarred  from 
his  accustomed  stimulus ;  perhaps  that  there  has  been  some  mental 
anxiety,  and  along  with  this,  his  last  few  nights  have  been  sleep- 
less. He  will  say  that  he  has  been  long  ailing,  that  his  present 
state  has  been  supervening  for  weeks  or  months,  and  will  often  be 
exceedingly  shy  of  telling  that  there  has  been  any  recent  aggrava- 
tion of  his  symptoms,  or  that  they  have,  as  we  may  be  well  assured 
from  other  sources,  all  come  on  within  a  few  days :  this  appears  to 
arise  from  a  consciousness  of  the  real  cause  of  his  malady,  which  he 
vainly  fancies  he  may  conceal ;  but  it  is  worthy  of  noting,  because 
it  might  lead  to  a  mistaken  diagnosis. 

The  pulse  is  soft,  often  large,  sometimes  weak  and  quick.  The 
tongue  is  evenly  coated  with  a  moist  creamy  fur.  The  skin  is 
warm,  frequently  perspiring;  but  in  the  early  stage  itmaybe  dry, 
and  often  exhaling  somewhat  of  a  rheumatic  odour ;  it  has  never 
the  heat  and  pungency  of  fever.  In  former  days,  when  delirium 
was  regarded  as  evidence  of  inflammation,  depletion  was  no  less  had 
recourse  to  in  this  than  in  the  delirium  of  typhus  fever,  or  of  ma- 
nia: but  in  this  practice  essential  symptoms  were  evidently  over- 
looked— that  of  the  pulse  and  the  moist  tongue;  and  just  as  in  at- 
tempting to  form  a  correct  diagnosis,  so  for  the  purpose  of  adopting 
sound  treatment,  the  totality  of  symptoms  must  be  considered  in  place 
of  the  mind  being  fixed  on  one  which  is  remarkably  prominent. 


127 


CHAPTER  XL 

GENERAL  EXAMINATION  OF  REGIONS  AND  ORGANS. 

Diseases  often  a  Compound  Phenomenon — All  Organs  ought  to  he 
examined — Negative  as  luell  as  Positive  Results  stated — Exami- 
natien  of  Brain  and  Nerves — of  Chest — of  Digestive  Organs — 
of  Urinary  Organs — of  Uterine  Functions — Appearance  of  shin. 

We  come  now  to  the  consideration  of  particular  organs,  and  it 
will  be  found  that  many  of  the  more  general  indications  sought  for 
in  the  earlier  part  of  the  investigation  have  an  especial  bearing 
upon  the  diseased  states  to  which  each  organ  is  liable.  These  the 
student  has  been  advised  to  note  as  he  proceeded  in  his  inquiry, 
whether  observed  in  the  details  of  the  history  of  the  case  ;  or  in  the 
general  symptoms  pertaining  to  the  skin,  the  pulse,  the  tongue,  the 
bowels  and  kidneys ;  or  in  the  appearance  and  position  of  the  patient. 
He  has  also  been  advised  not  to  attempt  to  form  a  judgment  on  the 
case  before  each  indication  has  been  fully  investigated,  and  the  seat 
of  any  complaint  of  pain  or  uneasiness  has  been  thoroughly  ex- 
amined: but  he  must  be  further  warned  that,  although  the  history 
of  the  case,  the  general  symptoms  and  the  particular  disorder,  cor- 
respond to  each  other  and  make  up  one  intelligible  whole,  he  has  not 
done  his  duty  to  himself  or  his  patient  unless  a  survey,  however 
rapid,  have  been  taken  of  the  condition  of  each  particular  organ. 
This  course  is  absolutely  necessary,  not  only  because  the  discovery 
of  some  obscure  change  may  throw  fresh  light  upon  the  totality  of 
the  symptoms,  and  ultimately  lead  to  a  different  and  more  cor- 
rect diagnosis ;  but  for  the  no  less  important  end  of  ascertaining 
whether  any  distinct  and  superadded  malady  exist,  which  may  most 
materially  modify  the  treatment. 

As  already  stated,  the  order  in  which  it  is  proposed  to  examine 
these  organs  follows  the  usual  division  into  regions, — the  head,  the 
chest,  the  abdomen,  and  the  extremities,  taking  the  dependent  struc- 
tures connected  with  the  principal  organs  situated  in  each  of  these 
regions  as  they  successively  come  before  us.  We  commence  with 
those  of  innervation,  the  brain,  spinal  cord,  and  nerves.  We  then 
take  those  of  respiration  and  circulation,  the  lungs,  the  heart,  and 
blood-vessels;  next,  those  connected  with  digestion,  beginning  with 
the  mouth,  the  stomach,  and  intestines,  with  their  investing  mem- 
brane, followed  by  the  liver,  spleen,  and  kidneys;  and,  lastly,  the 
ovaries  and  uterus.  After  these  will  be  noticed,  the  skin,  cellular 
tissues,  bones,  and  muscles. 

Throughout  the  inquiry  the  importance  of  system  in  every  step  of  the  investiga- 
tion has  been  pointed  out,  and  I  recommend  to  the  student  either  to  adopt  the  ar- 


128        EXAMINATION    OF    REGIONS    AND    ORGANS. 

raogemenl  just  mentioned,  or  to  form  for  himself  some  other  plan  more  consonant 
with  tin'  theory  of  disease  which  he  has  been  taught:  in  every  case  which  presents 
itself  tn  him  he  ought  to  follow  exactly  the  same  course  in  examining  the  different 
ins,  although  occasionally  he  may  find  it  advantageous  first  of  all  to  examine 
thoroughly  that  organ  which  the  history  of  the  case,  or  the  prominent  symptoms, 
whether  objective  or  subjective,  point  out  as  the  probable  seat  of  disease,  provided 
he  have  not,  from  general  indications,  come  to  the  conclusion  that  the  disease  is 
one  of  those  having  no  local  site,  which  have  formed  the  subject  of  the  preceding 
pages.  His  next  care,  in  either  case,  should  always  be  to  examine  in  a  definite 
c  the  various  organs,  with  their  local  phenomena,  and  to  note  in  his  case-book 
the  negative  as  well  as  positive  results  which  he  obtains. 

As  a  mere  matter  of  detail,  I  would  suggest  that  he  should  never  enter  in  bis 
notes  such  vague  expressions  as  "chest  healthy,"  but  state  explicitly  the  extent  of 
his  examination  and  its  results,  which  need  not,  however,  occupy  much  more  space. 
Thus,  to  take  the  case  of  the  chest,  he  may  state  simply  that  there  is  "no  com- 
plaint of  pain,  palpitation,  cough,  or  shortness  of  breathing;"  and  this  would  im- 
ply that  the  chest  had  not  been  examined  by  percussion  or  auscultation,  lie  may 
go  further,  and  record  that  "nothing  abnormal  has  been  discovered  by  percussion 
or  by  auscultation,"  or  he  may  limit  himself  to  some  particular  portion,  "breath- 
ing natural  under  the  clavicles,  at  the  back  of  the  chest,"  &c;  in  the  one  case,  he 
is  understood  to  have  examined  the  whole,  in  the  other,  only  a  part.  The  chief 
use  of  all  these  suggestions  is  to  establish  habits  of  accuracy;  but  if  he  should 
ever  wish  to  refer  to  these  cases  in  after  years,  if  it  should  be  his  lot  to  publish 
reports  of  them  for  the  information  of  others,  then  the  value  of  definite  statements 
will  more  clearly  appear. 

In  looking  for  indications  of  the  state  of  the  brain,  we  direct  our 
attention  to  the  mental  phenomena  of  consciousness  and  coherence: 
we  have  to  observe  whether  there  be  any  degree  of  slowness  of  ap- 
prehension, or  inability  to  understand  and  reply  to  questions; 
whether  there  be  any  wandering  of  thought,  as  expressed  by  talk- 
ing, or  muttering,  or  irrational  acts;  and  the  relations  which  these 
bear  to  each  other.  The  appearance  of  the  eye  is  closely  connected 
with  the  state  of  the  brain,  as  shown  in  strabismus,  and  dilatation 
or  contraction  of  the  pupil.  Deafness  is  another  important  indica- 
tion, especially  when  associated  with  discharge  from  the  ear:  so  is 
the  manner  of  speech,  slow,  hesitating,  or  imperfect.  These  ob- 
jective phenomena  are  not  all  equally  valuable;  strabismus  and 
deafness  may  have  nothing  to  do  with  the  present  state  of  the  brain  ; 
incoherence  may  be  simulated  by  hysteria:  want  of  consciousness 
by  obstinacy;  the  manner  of  speech  may  be  a  congenital  defect; 
but  they  are  each  suggestive  of  further  inquiry.  In  hysteria,  we 
often  meet  with  imitations  of  these  various  states,  talking  nonsense, 
singing,  pretended  sleep,  cataleptic  trance,  &c. ;  and  if  suspicion 
be  aroused  by  the  incongruity  of  these  with  the  general  state  of  the 
patient,  or  if  the  history  indicate  any  previous  symptoms  of  an  hys- 
terical character,  careful  watching  may  trace  consciousness  when 
there  is  pretended  stupor,  or  a  method  and  artifice  in  the  delirium, 
which  disease  never  presents. 

Subjective  phenomena  consist  of  statements  of  headache  and 
giddiness,  double  or  distorted  or  indistinct  vision,  tinnitus  aurium, 
perversions  of  smell  or  taste,  insomnia,  loss  of  memory,  &c. 

The  condition  of  the  nervous  system  generally  is  indicated  either 


EXAMINATION    OF    REGIONS    AND    ORGANS.  129 

by  the  condition  of  muscles,  in  paralysis,  convulsion,  or  spasm; 
or  by  sensations  more  purely  nervous,  pain,  numbness,  tingling,  or 
anesthesia. 

Disease  in  the  chest  is  shown  by  liviJity  of  face,  hurry,  labour, 
or  difficulty  in  breathing;  by  a  history  of  cough  or  sensations  of 
pain  and  dyspnoea.  These  more  probably  point  to  the  heart,  if 
palpitation  be  complained  of,  with  irregularity  of  pulse,  and  the 
dyspnoea  be  felt  in  mounting  a  hill  or  going  up-stairs:  they  rather 
point  to  disease  in  the  lungs,  if  cough  be  the  more  prominent 
symptom,  accompanied  by  expectoration. 

Diseases  of  the  digestive  organs  will  have  for  their  general  signs, 
loss  of  appetite,  or  a  sensation  of  craving;  pain  after  food,  or 
occasional  vomiting;  constipation;  diarrhoea;  disordered  states  of 
the  tongue  without  corresponding  indications  of  fever;  pains  in 
the  epigastrium  and  in  the  abdomen;  fulness,  tympanitic  distention, 
hardness,  tenderness,  or  fluctuation. 

For  the  kidneys  we  have  always  the  ready  means  of  inspecting 
the  urine,  and,  in  cases  of  doubt,  examining  it  chemically  and  mi- 
croscopically. Pains  in  the  loins,  in  the  groin,  testicle,  or  urethra: 
excessive,  scanty,  frequent,  or  painful  micturition  ought  always  to 
lead  to  further  inquiries. 

-  In  females,  it  is  generally  desirable  to  ascertain  the  condition  of 
the  menstrual  flux;  regular  or  irregular,  scanty  or  excessive,  the 
intervals  being  too  long  or  too  short,  and  its  appearance  being  ac- 
companied by  pain  or  uneasiness.  We  ought  also  to  learn  whether 
there  be  any  other  vaginal  discharge. 

Eruptions  on  the  skin,  or  distortions  of  bones  and  joints,  do  not 
readily  escape  observation;  but,  whenever  pain  on  the  surface  is 
complained  of,  an  inspection  of  the  part  is  advisable,  as  it  fre- 
quently solves  a  doubt  or  a  difficulty  which  all  the  description  in 
the  world  fails  to  unriddle. 

By  such  observations  we  determine  whether  further  examination 
of  any  particular  organ  may  be  necessary,  not  only  in  the  way 
of  instituting  a  more  minute  inquiry  into  symptoms,  but  also  of 
making,  when  possible,  a  physical  examination.  Those  connected 
with  states  of  innervation  have  a  high  importance  in  the  phenomena 
of  disease ;  but  here  the  physical  aid  is  wanting,  and  too  often  we 
cannot  get  beyond  a  simple  induction  based  upon  the  symptoms  both 
general  and  special;  and  to  them  we  now  proceed. 


130 


CHAPTER  XII. 

SEMEIOLOGY    OF    DISEASE    OF   THE   BRAIN. 

Causes  of  Obscurity. — History  imperfect. 

Div.  I. — Sy?nptoms  derived  from  Mental  Functions. — §  1,  Coma, 
or  Insensibility — §  2,  Stupor,  or  Unconsciousness, — §  3,  Insomnia. 
— §  4,  Delirium — of  Fever — of  Delirium  Tremens,  of  Inflam- 
matory Fever — of  Inflammation  of  Brain — of  Insanity. 

Div.  II. — Symptoms  from  Nervous  Sensibility. — §  1,  From  General 
Alterations  of  Sensibility — §  2,  From  the  Sense  of  Sight — §  3, 
From  the  Sense  of  Hearing — §  4,  From  Special  Sensations. 

Div.  III. — Alterations  in  Muscular  Movement. — §  1,  Spasmodic 
Action — §  2,  Paralysis. 

In  no  department  of  medicine  is  diagnosis  more  obscure  than  in 
that  upon  which  we  now  enter.  Enclosed  within  its  bony  case,  al- 
terations in  brain  structure  corresponding  to  phenomena  during  life 
can  never  be  discovered  till  after  death,  when  it  is  much  more  difficult 
to  trace  their  connexion;  and  numerous  and  diversified  as  are  the 
functions  of  the  organ  as  a  whole,  physiologists  have  yet  failed  to 
determine  with  any  degree  of  accuracy,  the  particular  regions  in 
which  its  various  powers  are  developed,  or  the  special  uses  of  many 
of  its  parts.  The  theories  of  Gall  and  Spurzheim,  had  they  been 
based  on  any  sufficient  groundwork  of  fact,  might  have  rendered 
essential  service  in  discriminating  the  site  of  diseased  action  ;  but 
experience  has  shown  that  perversions  of  those  mental  functions 
which  form  the  basis  of  their  system  do  not  depend  upon,  or  even 
correspond  with,  lesions  of  the  brain  in  those  regions  to  which  the 
names  of  organs  have  been  assigned;  and  it  yet  remains  to  be  proved 
that  special  portions  of  matter  are  at  all  necessarily  connected  with 
particular  actions  of  mind. 

In  addition  to  these  difficulties  we  find  one  set  of  head  symptoms, 
which,  from  their  transitory  character,  can  scarcely  be  supposed  to 
depend  on  change  of  structure;  others  which,  though  more  persis- 
tent, leave  no  trace  for  the  observation  of  the  anatomist:  both  of 
these  must  as  yet  be  considered  simply  as  disturbances  of  function, 
though  in  their  characters,  they  approach  so  nearly  to  the  symptoms 
of  structural  disease,  that  it  is  often  very  difficult  to  distinguish 
them.  On  the  other  hand,  the  evidences  of  structural  disease  of 
very  different  kinds  are  so  exactly  analogous,  that  the  physician  is 
often  at  a  loss  in  endeavouring  to  assign  to  each  its  exact  cause:  no 
less  perplexing  is  the  circumstance  that  the  obscurity  of  the  mental 
faculties  in  many  of  these  conditions  of  disease  deprives  us  of  the 
aid  which  a  true  account  of  the  patient's  sensations  might  afford, 


CONDITION    OF    THE    MENTAL    FACULTIES.  131 

as  they  are  blunted,  or  perverted,  or  the  power  of  analyzing  and 
describing  them  is  lost. 

For  the  same  reason,  it  is  not  unfrequently  impossible  to  obtain 
a  history  of  the  case  at  all  available  for  the  purposes  of  diagnosis; 
and  yet  no  part  of  the  inquiry  is  more  important.  Impracticable 
as  the  exact  discrimination  of  symptoms  may  be  at  the  time  of  ob- 
servation, each  case  is  generally  marked  by  successive  features  in 
its  history  which,  if  they  have  been  properly  noted  and  carefully 
studied,  will  throw  most  important  light  on  its  character  and  causes. 

The  pathology  of  the  brain  is  much  less  understood  than  it  ought 
to  be  in  the  present  day,  in  great  measure,  I  believe,  because  the 
importance  of  the  antecedent  phenomena  has  been  underrated,  and 
the  symptoms  have  been  read  apart  from  the  history.  Abercrombie 
is  deservedly  one  of  the  great  authorities  on  diseases  of  the  brain ; 
but  the  principles  of  diagnosis  cannot  be  learned  from  his  work  on 
this  subject,  because,  in  most  instances,  the  previous  history  of  his 
cases  is  so  meagre.  Let  it  be  remembered,  too,  that  in  the  present 
state  of  our  knowledge  this  record  of  the  symptoms  during  life  is, 
in  many  instances,  all  that  is  really  known  of  the  disease,  all  that 
is  really  valuable  in  treatment:  and  thus,  in  thiPcase,  diagnosis  be- 
comes, as  it  ought  to  be,  the  hand-maid  of  practice. 

Mental  alienation  forms  another  element  in  the  consideration  of 
diseases  of  the  brain,  which  is,  as  yet,  very  much  beyond  the  reach 
of  pathological  research.  Without  speaking  dogmatically,  it  may 
be  affirmed  that  scarcely  any  lesion  has  been  found  in  cases  of  in- 
sanity which  has  not  also  been  present  in  instances  in  which  the  mind 
has  been  perfectly  clear.  We  must  be  content  to  acknowledge  our 
ignorance  in  this  matter;  and  if  we  can  trace  our  general  resem- 
blances, and  classify  cases  according  to  some  well-known  types, — 
more  especially  if  we  can  discriminate  the  cases  in  which  structural 
change  exists  from  those  in  which  it  is  not  necessarily  present, — we 
shall  have  done  all  that  we  are  justified  in  attempting. 

It  will  probably  simplify  the  study  of  the  diseases  of  the  brain 
if,  before  entering  on  their  special  diagnosis,  this  chapter  be  devoted 
to  an  exposition  of  the  symptoms  which  are  more  directly  derived 
from  the  powers  of  innervation,  as  they  refer  to  the  mental  faculties, 
and  the  centripetal  and  centrifugal  nervous  actions — the  sensations 
and  the  muscular  movements  of  the  patient. 

Division  I. — The  Condition  of  the  Mental  Faculties. 

The  indications  derived  from  this  source  may  be  referred  to  two 
principal  heads — consciousness  and  coherence — perception  and  re- 
flection. These  correspond  to  two  very  clearly  defined  features  of 
disease  expressed  by  the  terms  coma  and  delirium.  Between  the  two 
extremes  we  find  an  almost  endless  variety  of  examples,  in  which 
they  are,  more  or  less,  blended  together,  where  it  is  scarcely  possi- 
ble to  tell  whether  the  perceptive  or  the  reflective  powers  be  most 
in  abeyance :  in  such  instances  there  is  partial  loss  of  consciousness, 


132  SEME  10  LOGY    OF    THE    BRAIN. 

with  a  certain  amount  of  insensibility  to  ordinary  stimulus,  and  con- 
fusion of  thought  without  active  delirium :  they  may  be  only  the 
transition  stage  from  one  state  to  the  other,  but  are  often  distinct 
from  cither.  CSma  is  related  to  sleep,  of  which  it  presents  the 
neatest  possible  exaggeration;  while  delirium  is  associated  with  in- 
somnia, which  is  its  invariable  attendant,  and  often  appears  as  its 
precursor. 

§  1.  Coma,  or  Insensibility. — Consciousness  is  entirely  suspend- 
ed ;  the  mind  is  a  perfect  blank;  the  patient  is  alike  deprived  of  the 
power  of  thought  and  expression,  and  of  the  knowledge  of  external 
things;  voluntary  action  has  altogether  ceased;  he  makes  no  reply 
to  any  question ;  he  may  be  pinched  or  pulled  about,  and  he  gives 
no  evidence  of  pain  or  annoyance;  the  muscular  movements  are  only 
those  of  organic  life,  or  such  as  may  be  excited  by  a  sort  of  reflex 
action,  or  unconscious  resistance.  In  such  cases  it  is  important  to 
discover  whether  the  absence  of  voluntary  action  depends  merely 
on  the  state  of  the  coma,  or  whether  there  be  distinct  paralysis  of 
some  of  the  muscles:  a  limb  placed  in  a  constrained  position  is 
moved  in  the  one  c™e  by  the  counterpoise  of  flexion  and  extension, 
in  the  other  it  remains  a  lifeless  object  in  the  condition  of  rest.  When 
paralysis  is  present,  the  extent  of  the  lesion  is  measured  in  some 
degree  by  the  number  and  variety  of  the  parts  implicated;  but  two 
conditions  are  chiefly  observed, — hemiplegia,  affecting  one  entire  la- 
teral half  of  the  body ;  paraplegia,  or  general  paralysis,  involving 
both  sides  alike.     (See  Div.  III.  §  2,  of  this  Chapter.) 

If  any  history  can  be  obtained,  we  have  to  inquire  how  the  pa- 
tient passed  into  his  present  state,  whether  it  supervened  suddenly, 
or  whether  gradually  increasing  stupor  and  somnolence  have  deep- 
ened into  coma;  and  in  the  former  case,  if  there  were  any  convul- 
sive movement  in  the  first  onset  of  the  attack.  When  no  one  was 
present  to  observe  these  circumstances,  we  may  still  learn  much  from 
the  position  in  which  the  patient  was  found :  as  it  points  to  the  sei- 
zure having  occurred  when  he  was  at  rest,  or  having  given  him 
warning  of  its  approach,  or  to  its  having  overtaken  him  in  the  midst 
of  action  or  exertion,  or  to  its  being  the  possible  result  of  accidental 
injury. 

This  condition  is  found  in  several  different  states,  a.  It  may  be  the  result  of 
a  fall  or  a  blow,  producing  in  the  first  place  concussion,  followed  by  extravasation, 
when  fracture  of  the  skull  has  occurred.  The  coma  of  concussion  is  not  so  deep, 
and  there  is  never  paralysis;  hemiplegia  points  especially  to  extravasation.  In 
their  further  progress  these  cases  may  pass  into  inflammation  and  serious  disor- 
ganization of  the  brain. 

b.  An  apoplectic  seizure,  in  which  the  patient  has  suddenly  fallen  down  insen- 
sible, without  convulsion,  or  with  convulsive  movements  very  slightly  marked. 
When  hemiplegia  co-exists  with  coma,  thus  suddenly  coming  on.  without  any 
trace  of  injury,  the  diagnosis  is  certain.  But  apoplectic  coma  may  exist  without 
paralysis,  and  then  its  presence  can  only  be  determined  negatively  by  the  exclu- 
sion of  all  other  possible  causes. 

c.  A  comatose  state  may  be  caused  by  intoxication,  or  opium.     In  neither  of 


PARTIAL    CO  II  A.  133 

these  does  it  come  on  so  rapidly;  intoxication  betrays  itself  by  the  odour  of  the 
breath;  and  in  poisoning  by  opium  the  person  may  generally  be  recalled  to  some 
degree  of  consciousness,  until  near  its  last  stage.  In  these  cases  the  previous  cir- 
cumstances, and  the  position  in  which  the  patient  is  found,  may  be  of  great  service 
in  guiding  our  opinion. 

d.  Coma  may  also  be  the  result  of  extensive  effusion  of  serum  into  the  ventricles 
of  the  brain.  It  is  difficult  to  conceive  how  this  can  happen  suddenly,  and  yet  it 
is  quite  certain  that  patients  are  seized  while  walking  along  the  street,  or  engaged 
in  their  usual  avocations,  with  a  fit,  generally  more  or  less  convulsive  in  character, 
followed  by  coma,  and  not  unfrequently  attended  with  either  paralysis  or  continued 
spasmodic  action  of  one  side  of  the  body.  The  diagnosis  rests  chiefly  on  two  points, 
the  existence  of  convulsions  in  the  primary  seizure,  and  the  extent  of  the  coma, 
which  is  scarcely  so  complete  as  in  apoplexy;  in  the  latter,  spasmodic  movements 
are  seldom  met  with.  A  history  of  previous  bad  health,  with  debility,  would  lead 
to  the  suspicion  of  effusion;  a  florid  face  and  a  full  habit  point  more  generally  to 
sanguineous  apoplexy. 

e.  Coma  supervenes  gradually  in  the  course  of  a  variety  of  diseases,  indicatino- 
either  a  morbid  condition  of  blood  circulating  in  the  brain,  or  progressive  disorgani- 
zation of  the  brain  itself:  cases  of  the  last  description  are  more  readily  recognised. 

§  2.  Stupor,  Unconsciousness,  or  Partial  Coma. — A  certain  de- 
gree of  unconsciousness  always  accompanies  delirium:  this  circum- 
stance will  be  subsequently  referred  to.  We  have  now  to  consider 
the  cases  in  which  stupor  is  the  prominent  symptom. 

When  coma  is  incomplete,  but  attended  by  hemiplegia,  or  convul- 
sive movements,  the  same  rules  of  diagnosis  are  applicable  as  to  com- 
plete coma.  The  phenomena  of  partial  unconsciousness  with  paraly- 
sis are  sometimes  very  remarkable.  The  attention  of  the  patient 
is  attracted  by  objects  about  him,  which  he  follows  in  their  move- 
ments with  his  eye ;  when  spoken  to,  he  turns  toward  the  speaker, 
and  seems  to  make  an  effort  to  reply,  and  it  may  be  conceived  that 
paralysis  alone  prevents  his  utterance:  on  closer  investigation,  how- 
ever, it  may  be  found  that,  though  the  attention  be  aroused,  the 
mind  receives  no  impression,  and  the  patient,  though  not  insen- 
sible, is  yet  unconscious. 

When  paralysis  is  not  present,  the  patient  seems  to  be  asleep, 
breathing  regularly  and  tranquilly,  but  he  is  found  to  be  in  a  very 
deep  sleep;  he  is  roused  with  great  difficulty,  and,  without  appear- 
ing to  awake,  he  resists  any  attempt  to  move  him  in  bed;  he  strug- 
gles when  he  is  undressed;  he  pulls  up  the  clothes  about  him  when 
he  is  uncovered;  and  even  when  thorous:hlv  aroused,  his  mind  is 
quite  confused.  Though  unable  to  answer  questions,  or  do  as  he  is 
directed,  he  will  make  very  distinct  combined  movements  in  changing 
his  position  in  bed,  and  placing  himself  comfortably,  as  if  he  wished 
again  to  go  to  sleep.  Here  delirium,  or  rather  incoherence  of  mind 
is  evidently  associated  with  partial  unconsciousness. 

Of  the  conditions  in  which  stupor  is  present,  we  find  (")  That  it  very  often  fol- 
lows upon  a  regular  epileptic  seizure:  indeed,  the  sleep  in  which  an  epileptic  fit 
almost  always  terminates  may  be  said  to  be  of  this  nature;  and,  though  generally 
very  transient,  it  may  occasionally  be  prolonged  even  for  days.  (&.)  It  is  also 
met  with  as  the  result  of  what  has  been  termed  transient  apoplexy,  or  of  concus- 
sion :  the  position  the  patient  was  found  in,  sometimes  aids  in  determining  whAer 
the  fall  was  the  cause  of  the  subsequent  state,  or  whether  it  happened  from  loss 


134  SEMEIOLOGT    OF    THE    BRAIN. 

of  consciousness.  Any  appearance  of  blood  about  the  mouth,  showing  the  tongue 
bo  have  been  bitten,  would  lead  us  to  believe  the  attack  had  been  one  of  epilepsy; 
but  in  diagnosis,  the  distinction  between  epileptiform  and  apoplectic  serai-coma  is 
unimportant,  and  only  demands  consideration  from  the  probability  of  recurrence 
in  the  one  and  the  smaller  chance  of  it  in  the  other,  (e:)  Semi-coma  from  intoxi- 
cation, of  poisoning  with  opium,  is  not  accompanied  by  t lie  same  degree  of  loss  of 
eons*  iousness.  When  the  patient  is  thoroughly  roused,  he  will  indicate  less  vacuity 
of  mind.  (</.)  A  comatose  state  sometimes  commences  very  insidiously,  without 
any  complaint  of  particular  ailment:  there  is  a  tendency  to  sleep;  the  patient  is 
awaked  with  difficulty,  and  when  roused  and  speaking  rationally,  he  breathes 
deeply  and  slowly,  and  seems  to  fall  asleep  even  with  his  eyes  open,  during  a 
pause  in  the  conversation;  at  first  there  is  little  confusion  of  thought,  except  mo- 
mentarily, on  awaking,  but  the  coma  gradually  deepens,  aud  is  not  nnfrequently 
attended  by  convulsions.  General  ill  health  may  have  preceded  it,  but  no  par- 
ticular derangement  of  any  organ  is  traced  in  the  history.  Such  a  condition  points 
very  certainly  to  albuminous  urine,  and  poisoning  of  the  blood  by  the  presence  of 
urea ;  the  probability  would  be  stronger  if  anasarca  had  previously  existed,  but 
the  point  may  generally  be  determined  by  examination  of  the  urine. 

§  3.  Insomnia  is  a  common  attendant  on  most  of  those  conditions 
with  which  delirium  is  associated.  The  report  made  of  want  of 
sleep  by  the  patient  himself  is  never  to  be  depended  upon,  as  to  its 
amount,  though  he  can  generally  say  whether  he  have  been  asleep  at 
all  during  the  night  or  not,  unless  the  mental  faculties  be  completely 
obscured.  Starting,  or  waking  up  suddenly,  or  in  a  fright,  are  phe- 
nomena less  frequently  relating  to  the  brain  than  to  the  heart  or 
stomach.  In  affections  of  the  brain  the  question  of  most  import- 
ance is  whether  sleeplessness  preceded  the  delirium,  or  were  only  as- 
sociated with  it. 

§  4.  Delirium. — The  term  delirium,  although  generally  applied 
to  that  wandering  of  mind  which  accompanies  certain  diseased 
states  of  the  body,  is  equally  applicable  to  the  confusion  of  thought 
which  supervenes  on  fixed  delusion,  and  constitutes  a  paroxysm  of 
acute  mania.  It  is  not  our  intention  here  to  inquire  into  all  the 
perversions  of  judgment,  eccentricities  of  behaviour,  or  alterations 
in  the  affections  and  moral  feelings,  which  are  met  with  in  persons 
whose  general  health  is  not  otherwise  affected,  and  which  give  rise 
to  the  fearful  apprehension  that  the  mind  is  becoming  unhinged; 
but  it  is  necessary  to  allude  to  the  phenomena  attending  an  attack 
of  acute  mania,  in  order  to  contrast  them  with  those  dependent  on 
acute  disease  within  the  cranium. 

The  presence  of  delirium  is  shown  by  incoherence  of  expression, 
traceable  to  hallucinations  and  illusions  which  have  generally  a  very 
fleeting  character.  Sometimes,  however,  they  assume  a  continuous 
form,  almost  resembling  fixed  delusion. 

Incoherence  is  always  combined  with  some  degree  of  unconscious- 
ness; and  it  is  worthy  of  consideration  how  far  this  proceeds  from 
obtuseness  of  perception  and  is  related  to  coma,  how  far  from  pre- 
occupation of  mind  and  confusion  of  thought.  When  coma  is 
complete,  there  can  be  no  expression  of  delirium;  but  when  roused 
from  a  state  of  stupor,  the  patient  may  either  be  able  to  put  out 
his  tongue  when  desired  to  do  so,  and  to  give  tolerably  rational  and 


DELIRIUM.  135 

consistent  answers,  or  he  may  only  reply  by  a  vacant  stare  or  an 
incoherent  expression,  showing  that  delirium  is  present  as  well  as 
stupor.  In  delirium  there  may  be  the  same  impossibility  of  obtain- 
ing a  rational  answer,  simply  from  pre-occupation  and  incoherence: 
the  question  fails  to  give  rise  to  any  corresponding  idea  in  the  mind 
of  the  patient.  This  character  of  unconsciousness  is  very  different 
from  that  depending  on  stupor;  it  is  often  only  partial,  as  indicated 
by  his  not  recognising  individuals  around  him,  and  passing  his 
fseces  and  urine  in  bed,  while  an  impression  stronger  than  usual 
produces  a  rational  act.  During  the  time  that  he  is  talking  or 
muttering  to  himself,  or  addressing  fanciful  persons  whom  he 
imagines  to  be  near  him,  he  may  be  recalled  by  firmness  of  manner 
to  such  a  state  of  consciousness  as  to  give  a  coherent  answer,  or  to 
do  as  he' is  directed. 

One  feature  common  to  all  forms  of  delirium  is  that  restlessness 
which  prompts  the  patient  to  attempt  to  get  out  of  bed,  and  this 
even  when  the  strength  is  so  exhausted,  that  the  act  might  be  sup- 
posed to  be  impossible.  There  is  almost  always  distinct  exacerba- 
tion at  nighty  and  this  is  most  marked  in  the  slightest  cases.  De- 
lirium at  night  is  often  observed  when  there  is  no  indication  of 
wandering  of  thought  by  day;  a  patient  who  only  mutters  and 
talks  by  day  will  be  noisy  and  unmanageable  at  night;  and  it  is 
perhaps  only  when  mental  excitement  is  at  its  highest  pitch  during 
the  day  that  it  does  not  appear  to  be  increased  as  evening  ap- 
proaches. 

Under  the  term  incoherence  of  expression  we  include  all  the 
inconsistent  acts  as  well  as  words  of  delirium.  These  are  as  varied 
as  the  illusions  under  which  the  unhappy  patient  labours;  .but  I 
think  it  may  generally  be  observed  that  they  are  more  uproarious 
as  the  character  of  the  delusion  is  more  definite.  Thus  we  find 
one  patient  noisy  and  violent,  with  difficulty  kept  in  bed  or  re- 
strained from  doing  a  mischief  to  himself  or  others,  but  always 
governed  by  some  prominent  idea;  another,  who  only  mutters  and 
rambles  on  in  the  most  inconsistent  manner;  while  a  third  is  still 
and  listless,  either  giving  no  answer  at  all  or  one  wholly  incongru- 
ous. All  are  liable  to  pass  their  faeces  and  urine  in  bed ;  not  from 
unconsciousness  of  the  act,  but  from  ignorance  of  its  impropriety. 
In  this  view  of  the  subject,  the  cases  are  sometimes  classed  as  ex- 
amples of  active  and  passive  forms  of  delirium. 

It  is  most  important  to.  remember  that  delirium  is  not  evidence 
of  inflammation,  and  that  in  by  far  the  majority  of  cases  it  is  not 
accompanied  by  any  inflammatory  action  at  all  within  the  cranium. 
The  history  of  the  case  and  the  correlative  symptoms  must  be  care- 
fully studied,  because  it  is  so  constantly  a  concomitant  of  other 
diseases. 

a.  It  occurs  in  most  severe  attacks  of  fever. 

b.  It  is  constant  in  delirium  tremens. 

e.  It  is  often  associated  with  inflammation  of  some  other  organ, 


136  SEMEIOLOGY    OF    THE    BRAIN. 

causing  alteration  in  the  blood,  of  which  pneumonia  is  perhaps  the 
most  common. 

d.  It  may  supervene  in  the  course  of  acute  rheumatism  or  ery- 
sipelas. 

e.  When  the  disease  is  confined  to  the  brain,  it  may  be  linked 
with  the  tubercular  diathesis; 

/.   Or  it  may  depend  on  simple  inflammation. 

//.  It  may  be  an  evidence  of  maniacal  affection. 

During  the  existence  of  delirium  all  the  organs  will  require 
closer  investigation  to  elicit  evidence  of  disease,  than  when  the 
symptoms  are  unassociated  with  mental  phenomena,  because  they 
are  so  much  obscured  by  the  unconsciousness  of  the  patient  to  sen- 
sations of  pain  or  distress:  thus,  an  individual  suffering  from  acute 
rheumatism  will  make  movements  in  his  delirium,  which  Avould  have 
been  exquisitely  painful  to  him  if  his  perception  had  not  been 
blunted;  or  one  labouring  under  severe  pneumonia  or  phthisis  will 
cease  to  cough  or  suffer  any  inconvenience  from  the  accumulation 
of  secretion  in  the  lungs.  These  points  ought  never  to  be  over- 
looked. 

a.  In  fever  the  delirium  is  very  often  of  a  quiet  character,  with  considerable 
prostration,  inattention  to  surrounding  objects,  and  unconnected  muttering  and 
rambling:  sometimes,  however,  the  patient  is  very  noisy  and  excited,  and  can 
scarcely  be  kept  in  bed,  and  this  especially  happens  when  the  functions  of  the  liver 
are  disordered.  It  follows  upon  the  insomnia  of  the  early  stages,  coming  on  at 
first  only  at  night,  and  continuing  throughout  to  have  nocturnal  exacerbations: 
there  is  great  iusensibility  to  external  impressions,  and  frequently  marked  deaf- 
ness. In  addition  to  these  characters  of  the  delirium  there  are  the  special  indi- 
cations of  fever,  as  distinct  from  those  of  inflammation;  the  eyes  are  dull  and  suf- 
fused, not  brilliant  and  ferrety,  the  movements  are  feeble  and  tremulous,  and  the 
pulse  is  essentially  weak  and  soft:  these  characters  have  been  already  detailed. 
(See  Chap.  IV.  §  1,  Continued  Fever.) 

b.  In  delirium  tremens  it  is  accompanied  by  peculiar,  hurried  movements  and 
muscular  tremor ;  but  there  is  also  something  in  the  character  of  the  delirium  quite 
distinctive;  the  mind  generally  runs  upon  one  subject  which  is  attended  with 
anxiety  or  distress,  either  upon  some  business  engagement  which  cannot  be  ful- 
filled, or  on  the  presence  of  some  disagreeable  or  disgusting  object — some  crea- 
ture crawling  about  the  bed,  sbme  horrible  death's  head  staring  at  the  patient.  It 
is  a  busy  and  active,  but  not  a  violent,  delirium:  the  patient  is  generally  ready 
enough  to  do  as  he  is  told,  will  for  the  moment,  perhaps,  abandon  his  imaginary 
pursuit  to  answer  questions  apparently  in  a  rational  manner,  and  put  out  his 
tongue  when  desired;  but  quite  as  often  he  still  keeps  hold  of  the  bed-clothes  un- 
der the  idea  that  they  are  some  other  object,  and  while  answering  the  questions 
addressed  to  him,  continues  to  issue  orders  to  some  of  his  imaginary  subordinates. 
There  is  always  great  restlessness;  getting  out  of  bed,  pulling  about  the  bed-clothes, 
constant  talking,  generally  in  a  loud  tone  of  voice,' the  same  definite  object  always 
predominating  in  the  mind,  to  the  entire  exclusion  of  surrounding  realities.  Sleep- 
lessness is  an  invariable  precursor  of  this  form  of  delirium,  preceding  by  some  days 
its  full  development,  but  the  nocturnal  exacerbations  are  rarely  so  marked  as  in 
fever. 

The  moist,  creamy  tongue,  the  soft  pulse,  the  perspiring  skin  are  most  import- 
ant indications,  because  they  not  only  materially  aid  the  diagnosis,  but  form  the 
basis  of  rational  treatment. 

c.  The  delirium  of  pneumonia  very  closely  resembles  that  of  fever;  but  when  it 
occurs  in  persons  of  dissipated  habits,  may  more  nearly  approach  to  delirium  tre- 
mens; just  as  happens  when  such  persons  meet  with  severe  injuries,  or  suffer  from 


DELIRIUM    OF    CEREBRAL    DISEASE.  137 

erysipelas  or  rheumatism.  Hence  the  delirium  itself  does  not  aid  our  diagnosis, 
inasmuch  as  its  causes,  and  consequently  its  manifestations,  are  so  analogous: 
when  resembling  that  of  fever,  the  pneumonia  has  an  adynamic  type  like  the  com- 
mon continued  fever  of  the  present  day,  and  to  the  accompanying  condition  of  the 
blood  the  delirium  is  due ;  while,  when  it  approaches  in  character  to  delirium  tre- 
mens, the  impression  made  on  the  nervous  system  by  habits  of  dissipation  acts  as 
the  predisposing  cause,  and  the  pneumonia  merely  takes  the  place  of  any  other 
depressing  influence  in  exciting  the  delirium. 

The  important  point  in  diagnosis  is,  that  the  pneumonia  should  not  be  over- 
looked; and  a  correct  opinion  will  in  all  cases  very  much  depend  on  systematic 
investigation,  when  delirium  is  present  along  with  internal  inflammation.  The 
history  must  be  carefully  inquired  into,  the  general  symptoms  weighed,  and  the 
condition  of  all  the  organs  closely  examined  into.  In  the  absence  of  more  de- 
cided symptoms,  quick  breathing,  a  dusky  flush  on  the  face,  and  especially  rusty 
sputa,  are  unlike  fever ;  dryness  of  the  tongue  and  smallness  of  the  pulse,  unlike 
genuine  delirium  tremens. 

Inflammation  of  the  heart  is  another  important  condition  which  must  be  sought 
for  in  obscure  cases  of  delirium.  It  is  probable  that,  in  cases  where  this  has  been 
found  as  the  sole  evidence  of  disease,  the  true  explanation  is  rather  to  be  sought 
in  the  association  which  has  next  to  be  studied. 

d.  Delirium  supervening  in  the  course  of  acute  rheumatism  and  erysipelas. 
These  forms  of  delirium  may  be  taken  together,  because  there  is  alleged  to  be  in 
each  an  occasional  metastasis  to  the  brain:  in  the  latter  the  preceding  state  can- 
not be  mistaken,  but  in  the  former  the  occurrence  of  inflammation  of  the  heart 
may  be  accompanied  by  a  retrocession  of  the  affections  of  the  joints,  or  may  even 
be  almost  the  only  organ  which  rheumatism  attacks;  in  the  present  state  of  our 
knowledge  we  must  look  upon  idiopathic  inflammation  of  that  organ  as  being  at 
least  extremely  rare. 

It  is  quite  certain  that  delirium  of  a  very  active  character  may  occur  in  both 
these  disorders  without  any  inflammation  of  the  brain.  In  acute  rheumatism  it 
generally  commences  as  a  slight  wandering  at  night,  or  is  at  first  only  marked  by 
some  peculiarity  of  manner;  it  then  passes  rapidly  into  delirium  of  a  noisy  kind, 
which  is  often  accompanied  by  great  obstinacy  and  refusal  to  answer  questions  or 
to  take  food  and  medicine;  and  sometimes  by  local  or  general  spasm:  altera  par- 
tial or  complete  remission,  the  delirium  is  apt  to  recur,  and  it  then  passes,  in  fatal 
cases,  into  coma  and  death.  In  erysipelas  it  has  a  less  active  character  generally; 
it  has  much  analogy  to  that  observed  in  fever;  beginning  with  the  same  wander- 
ing at  night,  it  passes  into  the  low  muttering  and  rambling  form,  and  rarely  as- 
sumes a  noisy  character:  in  fatal  cases  this  also  terminates  in  coma.  In  persons 
of  dissipated  habits  and  dilapidated  constitutions,  the  delirium  attendant  on  both 
of  these  diseases  more  commonly  simulates  delirium  tremens;  and  this  is  an  im- 
portant point  in  diagnosis,  because  it  decides  the  question  at  once  of  whether  there 
be  inflammation  of  the  brain  or  not.  It  is  certain,  under  such  circumstances,  that 
the  delirium  is  not  due  to  metastasis. 

Metastasis,  in  the  true  sense  of  the  word,  must  be  exceedingly  rare  in  erysipe- 
las:  it  may  be  conceived,  but  is  not  known  as  part  of  its  clinical  history;  I  mean 
the  disappearance  of  the  swelling  and  redness  of  the  part  coincidently  with  the  in- 
cursion of  head-symptoms.  On  the  other  hand,  considering  the  nature  of  the  dis- 
ease, that  it  is  not  associated  with  exudation  of  lymph,  but  of  serum,  it  is  quite 
possible  that  serous  effusion  may  be  due  to  extension  of  erysipelatous  inflamma- 
tion to  the  membranes  of  the  brain ;  but  it  is  quite  as  probable  that  the  delirium 
is  merely  the  evidence  of  altered  conditions  of  blood,  of  the  circulation,  and  of  the 
nervous  energy,  as  in  the  other  forms  already  noticed;  and  this  is  the  more  likely, 
because  it  exists  without  as  well  as  with  effusion.  In  diagnosis  we  have  only  to 
remember  that  the  delirium  of  erysipelas  is  not  associated  with  inflammation  of 
the  structure  of  the  brain,  or  with  such  inflammation  of  its  membranes  as  leads  to 
effusion  of  lymph  or  of  pus;  because  this  is  the  all-important  point  in  treatment. 
In  rheumatism,  again,  something  very  like  metastasis  to  the  heart  occurs,  and 
there  may  be  something  like  metastasis  to  the  brain:  the  disease  is  essentially  erra- 
tic.    But  in  by  far  the  larger  number  of  cases  we  are  sure  that  the  delirium  does 


138  SEMEIOLOGY    OF    THEBRAIN. 

not  depend  on  metastasis,  because  rheumatic  inflammation  of  the  joints,  of  the 
heart,  and  of  the  pleura  is  accompanied  by  exudation  of  lymph,  and  rheumatic 

inflammation  of  the  membranes  of  the  brain  should  be  similarly  evidenced  by  the 

Since  of  lymph.  Post-mortem  examinations  prove  that  this  is  very  rare  in- 
eed:  and  we  are  therefore  justified  in  assuming  that,  unless  the  evidence  of  in- 
flammation within  the  cranium  derived  from  other  sources  be  very  decided,  deli- 
rium, following  upon  or  accompanying  acute  rheumatism,  is  to  be  classed  along 
with  that  of  fever,  of  pneumonia,  of  erysipelas,  and  to  be  taken  merely  as  evidence 
of  blood-poisoning;  and  this  so  much  the  more  certainly  if  there  be  no  retrocession 
of  the*affection  of  the  joints,  or  if  it  have  been  preceded  by  inflammation  of  the 
heart. 

In  one  of  the  less  acute  forms  of  rheumatism,  the  synovial  membrane  is  dis- 
tended with  serum,  not  with  lymph,  and  several  cases  are  on  record  in  which  the 
sudden  disappearance  of  the  effusion  in  the  joint  has  been  followed  by  an  equally 
sudden  occurrence  of  effusion  in  the  brain.  In  these  cases  the  symptoms  were 
rather  of  coma  or  stupor  than  delirium:  they  perhaps  are  the  only  real  instances 
of  metastasis  met  with  in  practice. 

e.  Delirium,  when  not  symptomatic  of  disease  in  the  blood,  or  in 
other  organs  acting  through  the  blood,  must  be  taken  as  indicative 
of  changes  going  on  within  the  cranium.  It  will  be  best  first  to 
consider  that  condition  which  is  linked  with  the  tubercular  diathesis, 
in  order  that,  by  a  process  of  exclusion,  we  may  arrive  at  those 
which  are  uncomplicated.  The  association  between  tubercles  and 
inflammation  of  the  brain  was  first  clearly  recognised  in  what  is 
called  the  acute  hydrocephalus  of  childhood:  it  is  not  necessary 
that  actual  deposit  of  scrofulous  matter  within  the  cranium  should 
take  place,  though  it  be  frequently  found  there  after  death.  Deli- 
rium is  by  no  means  a  constant  accompaniment  of  hydrocephalus; 
in  fact,  in  early  childhood,  before  the  reasoning  powers  are  deve- 
loped, it  is  not  only  difficult  to  take  cognizance  of  such  a  state,  but 
experience  teaches  that  the  disturbance  is  more  likely  to  be  mani- 
fested by  convulsions  than  by  mental  phenomena. 

The  association,  however,  is  not  limited  to  childhood;  in  youth, 
or  even  in  adult  age,  the  same  condition  of  inflammation  accom- 
panies the  tubercular  diathesis,  and  must  be  presumed  to  spring 
from  it.  Here,  delirium  is  one  of  the  earliest  symptoms  of  the 
disease:  its  character  sometimes  resembles  that  of  fever,  and  then 
the  diagnosis  is  extremely  difficult,  because  all  the  general  symptoms 
of  fever  are  present;  the  pulse  is  quick,  the  skin  hot,  the  tongue 
coated,  and  the  bowels  relaxed ;  like  fever,  the  tubercular  diathesis 
is  apt  to  be  associated  with  diarrhoea,  ending  in  ulceration ;  as  in 
fever,  too,  the  pulse  is  essentially  weak,  and  tends  to  be  rapid;  it 
is  only  distinguished  by  its  great  variableness.  Pain  in  the  head 
is  more  constant,  there  is  often  mu*h  heat  externally,  and  the 
delirium  is  more  pronounced  and  more  constant;  in  its  commence- 
ment it  is  not  so  distinctly  a  nocturnal  state  with  total  remission  by 
day  as  in  fever,  and  it  is  generally  developed  earlier  in  the  disease. 
Such  circumstances  must  at  least  lead  to  inquiry  whether  there  be 
any  evidence  of  tubercle. 

The  delirium  sometimes  assumes  quite  a  different  form :  it  is  such 
as  has  been  called  passive  delirium ;  there  is  scarcely  any  talking 


DELIRIUM    OF    CEREBRAL    DISEASE.  139 

or  restlessness;  the  patient  lies  in  a  partially  unconsc?ous  state, 
taking  little  note  of  surrounding  objects;  confused  in  his  ideas, 
answering  either  not  at  all,  or  in  a  very  unintelligible  manner,  any 
question  put  to  him,  and  unable  correctly  to  describe  his  condition 
or  his  sensations ;  he  passes  his  urine  and  feces  involuntarily,  and 
is  with  great  difficulty  induced  to  put  out  his  tongue  and  to  take 
his  food  or  his  medicine;  the  tongue  is  less  generally  coated,  some- 
times tolerably  clean,  occasionally  unnaturally  raw  and  glazed. 

In  the  further  progress  of  the  disease,  symptoms  of  pressure  on 
the  brain  develop  themselves  in  either  case ;  there  is  dilatation  of 
the  pupil,  and  the  supervention  of  coma,  not  from  sheer  exhaustion, 
but  as  the  effect  of  active  effusion. 

The  history  of  the  case  generally  records  ill  health  of  some 
standing:  the  more  acute  attack  has  been  insidious;  the  febrile 
symptoms  have  not  set  in  suddenly  with  rigor  and  general  depres- 
sion ;  there  has  been  marked  pain  of  the  head  and  delirium,  as  a 
very  early  symptom.  It  is  to  be  remembered  that  we  are  not  now 
speaking  of  the  diagnosis  of  scrofulous  inflammation,  but  of  the 
delirium  occasionally  accompanying  it,  which  is  especially  seen  in 
youth  and  adult  age:  in  such  cases  this  mode  of  incursion  is  the 
usual  one,  though  the  disease  may  also  set  in,  as  it  does  more  fre- 
quently in  childhood,  by  severe  vomiting  and  constipation,  or  by 
convulsions.  As  it  is  in  the  lungs  that  we  can  most  surely  trace 
the  development  of  tubercle,  it  is  to  these  organs  that  we  must 
especially  look  for  aid  in  our  diagnosis ;  the  condition  of  the  abdomi- 
nal viscera  must  also  be  inquired  into;  and  we  note  the  occurrence 
of  haemoptysis,  or  the  liability  to  diarrhoea,  as  important  features 
in  the  narrative  of  the  case. 

/.  Although  delirium  can  by  no  means  be  taken  as  evidence  of 
inflammation  in  the  brain,  it  is  a  very  constant  symptom  when  the 
superficial  structure  and  membranes  are  the-  seat  of  acute  inflam- 
matory action.  Thetdiagnosis,  however,  rests  less  on  the  presence 
of  delirium  than  on  other  points  to  be  noticed  hereafter:  it  is  ge- 
nerally of  a  more  violent  kind  than  any  yet  referred  to,  and  more 
resembles  acute  mania;  the  patient  is  noisy  and  unmanageable, 
attempts  to  get  out  of  bed,  tosses  the  bed-clothes  about  in  confusion, 
and  would  often  injure  himself  or  others  if  not  restrained ;  it  is  less 
characterized  by  fixed  delusion  than  by  wild  shouting  and  scream- 
ing; it  is  usually  impossible  to  obtain  an  answer  to  any  question,  or 
to  fix  the  attention  on  anything  that  is  said. 

YVhen  such  a  condition  exists,  we  seek  for  evidence  of  inflamma- 
tion in  quickness  of  pulse,  flushing  of  face,  throbbing  of  temporal 
arteries,  intolerance  of  light  or  of  sound,  indications  of  spasm, 
convulsion,  or  paralysis,  history  of  pain,  vomiting  and  constipa- 
tion.    (See  Chap.  XIIL,  §  2.) 

g.  The  Delirium  of  Insanity. — Cerebral  pathology  is  yet  so  en- 
tirely at  fault  in  the  correct  association  of  certain  mental  states 
with  special  change  of  nervous  structure,  that  no  attempt  will  be 


140  SEMEIOLOGY    OF    THE    BRAIN. 

made  to  classify  the  various  features  of  mania ;  the  question  of 
diagnosis  need  not  be  further  pursued  than  to  point  out  the  dis- 
tinctions between  the  delirium,  which  is  a  symptom  of  recognised 
conditions  of  disease,  and  that  which  is  more  properly,  in  the  pre- 
sent state  of  our  knowledge,  considered  as  merely  mental.  Neither 
does  it  come  within  the  scope  of  a  manual  of  diagnosis  to  discuss 
whether  or  not  alienation  or  perversion  can  be  predicated  of  mind, 
independently  of  disease  of  the  organ  of  mind;  but  there  seems 
to  be  no  greater  difficulty  in  acknowledging  this  possibility  than  in 
confessing  to  the  truth  which  Revelation  teaches,  of  the  fallen  and 
imperfect  condition  of  the  mind  of  man,  as  a  moral  and  responsi- 
ble creature.  And  as  it  is  possible,  by  purely  psychical  processes, 
to  correct  perversions  of  the  moral  faculties,  and  by  similar  means 
to  restore  the  mental  faculties  in  what  is  called  the  moral  treat- 
ment of  the  insane,  a  curious  analogy  is  thus  established  between 
them.  It  is  enough  for  us  that  the  terms  mental  alienation,  insa- 
nity, or  unsoundness  of  mind  are  used  to  designate  conditions  differ- 
ent from  those  which  we  are  acquainted  with,  as  diseases  of  the 
brain. 

As  these  terms  imply,  the  prominent  character  of  the  state  we 
are  now  discussing  is  an  aberration  of  the  reasoning  faculties,  the 
patient  is  unable  to  form  a  correct  judgment  on  ordinary  premises; 
and  this  may  be  limited  to  some  particular  subjects,  or  may  apply, 
more  or  less,  to  all.  But,  besides  the  inability  to  reason  correctly, 
there  is  generally  a  coexistent  perversion  of  some  particular  facul- 
ty, moral  or  intellectual,  or  of  some  one  of  the  affections,  giving 
in  each  case  its  peculiar  stamp  to  the  form  of  insanity,  and  per- 
haps the  only  real  cause  why  the  judgment  is  erroneous.  From 
this  perversion  springs  the  fixed  delusion  so  often  present  in  the 
insane — a  false  idea  permanently  engrafted  in  the  mind,  which,  in 
its  turn,  leads  to  the  production  of  hallucinations  and  illusions ; 
these  are  independent  of  delirium,  which  wa>  are  now  considering 
as  a  symptom  of  acute  mania.  When  this  condition  is  superadded, 
all  the  ideas  are  thrown  into  confusion,  the  fixed  delusion  itself  may 
for  a  time  be  lost,  or  be  in  abeyance,  or  may  acquire  greatly  in- 
creased force;  some  other  prominent  idea  may  take  possession  of 
the  mind;  or  there  may  be  perfect  incoherence.  The  delirium  of 
insanity  exactly  corresponds,  in  these  respects,  to  the  delirium  of 
disease,  and  is  only  more  distinct  and  more  exalted.  It  comes 
nearest  to  that  of  acute  inflammation,  with  which  it  is  often  ex- 
actly identical,  and  the  diagnosis  must  be  based  on  the  mode  of 
incursion  and  the  indications  derived  from  other  symptoms. 

"When  the  attack  has  been  ushered  in  by  perversion  of  the  af- 
fections, alterations  in  temper  or  spirits,  or  by  peculiarity  of  man- 
ner in  acting  or  speaking,  especially  when  these  can  be  traced  to 
some  cause  of  anxiety,  bad  news,  or  sudden  fright,  it  is  probably 
mania.  Now  and  then,  if  the  reports  of  friends  may  be  trusted, 
cases  of  delirium  tremens  commence  in  a  similar  manner;  and  we 


DELIRIUM    OF    INSANITY.  141 

must  guard  against  such  a  mistake  by  ascertaining  whether  there 
have  been  dissipation  or  excess  prior  to  its  occurrence.  If  due  re- 
gard be  had  to  those  symptoms  referrible  to  the  "general  state"  of 
the  patient,  the  skin,  the  pulse,  and  the  tongue,  faulty  diagnosis, 
which  cannot  always  be  avoided  in  diseases  of  the  brain,  will  not 
lead  to  errors  in  treatment;  rational  as  opposed  to  empirical  reme- 
dies, can  alone  give  satisfactory  results. 

So  likewise,  in  discriminating  the  delirium  of  acute  inflammation 
from  that  of  acute  mania,  besides  that  light  which  is  thrown  on 
the  case  by  the  ascertained  absence  of  peculiarity  or  perversion  of 
ideas  prior  to  its  appearance,  still  more  information  may  be  gained 
by  a  strict  examination  of  all  the  symptoms  yet  to  be  detailed, 
which  point  to  inflammation  of  the  brain  as  their  cause. 

As  we  shall  not  have  another  opportunity  for  discussing  the  subject  of  insanity, 
a  few  remarks  on  its  more  general  features  may  not  be  inappropriate  in  this  place. 
Its  forms  are  very  varied :  the  patient  may  be  morose,  taciturn,  or  reserved ;  or  he 
may  be  loquacious,  noisy,  or  unmanageable;  any  one  or  more  of  the  faculties  and 
affections  may  be  the  especial  seat  of  the  disease;  his  delusions  may  be  fixed  and 
invariable,  or  may  comprehend  a  constantly  changing  series  of  fancies;  and  these, 
again,  are  usually  accompanied  by  the  presence  of  hallucinations  and  illusions, — 
mental  impressions  which  seem  to  the  patient  to  be  produced  by  objects  affecting 
his  senses,  when  in  truth  they  originate  in  the  mind  itself.  These  imaginings  of 
the  insane  are  very  different  from  what  may  be  more  properly  termed  alterations 
in  sensibility:  in  the  latter  the  force  of  true  impressions  on  the  nerves  is  exagge- 
rated or  diminished  in  intensity,  or  their  character  is  confused  and  indistinct:  in 
the  former,  the  mental  conception*  is  referred  to  the  organs  of  sense,  where  im- 
pressions are  felt  exactly  analogous  to  those  which  would  be  received  if  the  cor- 
responding object  had  a  real  existence:  in  the  one  the  sensations  are  vague  and 
ill-defined,  in  the  other  they  seem  distinct  and  clear. 

In  the  strict  application  of  terms,  the  word  hallucination  implies  that  no  object 
is  present  to  stimulate  the  organ  to  which  the  idea  formed  in  the  mind  is  referred; 
while  in  illusions,  existing  objects,  which  in  the  first  instance  produce  the  stimu- 
lus, are  clothed  by  the  mind  in  characters  more  or  less  foreign  to  their  true  na- 
ture, and  these  are  so  inextricably  blended  with  the  sensation  originally  produced, 
as  to  give  rise  to  the  belief  that  the  resulting  idea  is  wholly  derived  from  an  ex- 
ternal impression. 

Morbid  fancies  are  not  limited  to  insanity;  but  when  the  judgment  is  perverted 
or  lost,  they  are  not  corrected  by  the  force  of  true  impressions  opposed  to  them, 
and  hence  their  permanence  and  domination  in  insanity  and  delirium. 

In  mental  affections  the  patient  is  usually  out  of  health,  but  there  are  no  gene- 
ral symptoms  invariably  present:  the  tongue  is  often  foul,  the  bowels  confined, 
and  during  the  paroxysm  of  acute  mania  the  pulse  maybe  somewhat  accelerated, 
but  we  seek  in  vain  for  evidence  of  inflammation,  for  convulsion,  or  paralysis,  ex- 
cept when  imbecility  succeeds  epilepsy,  or  paralysis   accompanies  fatuity:   the 
svmptoms  referrible  to  the  nervous  system  neither  betray  increased  sensibility, 
nor  loss  of  power,  but  consist  of  deceptions  of  the  nerves  of  sense,  and  delus^ms 
regarding  external  objects,  which  may  extend  to  the  condition  of  the  whole  body, 
or  only  that  of  some  particular  organ.     The  most  prominent  exception  to  this  ge- 
neral rule  of  diagnosis  is  found  in  the  condition  of  puerperal  mania,  which  seems 
to  hold  a  place  somewhat  intermediate  between  mental  alienation  and  the  delirium 
of  disease,  being  allied  to  the  former  in  the  perversion  of  the  affections  and  the 
reason,  and  the  absence  of  distiuct  signs  of  disease,  while  it  is  assimilated  to  the 
latter  in  its  coincidence  with  the  peculiar  state  of  health  belonging  to  pregnancy 
and  parturition.     Its  diagnosis  cannot  be  based  upon  any  peculiarity  in  the  mani- 
festation of  the  mental  phenomena,  but  simply  on  the  fact  of  its  occurring  during 
the  puerperal  state,  and  occasionally  after  prolonged  lactation,  when  perhaps  it  is 


142  SEMEIOLOGY    OF    THE    BRAIN. 

rather  to  l>e  regarded  as  mania  occurring  in  a  condition  of  anrcmia,  than  mania 
cidted  with  pregnancy.  In  its  commencement  there  is  almost  always  deli- 
rium: after  its  subsidence  the  patient  remains  in  a  condition  of  temporary  un- 
soundness of  mind:  undoubtedly  faulty  nutrition  is  one  of  the  antecedent  circum- 
stances, but  there  is  something  more — hereditary  tendency,  insanity  in  other  mem- 
bers  of  the  family,  or  individual  predisposition,  as  indicated  by  repeated  attacks 
in  successive  pregnancies;  at  all  events,  it  is  alike  different  from  the  blood-poison- 
ing of  livers,  inilammatious,  &c,  and  from  delirium  depending  ou  change  of  struc- 
ture in  the  brain. 

Division  II. — Alterations  of  Sensibility. 

Sensation  may  be  morbidly  keen,  or  it  may  be  obtuse  and  even 
entirely  lost,  or  it  may  be  perverted;  each  of  these  conditions  ex- 
tends, more  or  less,  to  the  whole  nervous  system,  or  is  limited  to 
particular  organs.  With  reference  to  all  alterations  of  sensibility, 
a  distinction  must  be  made  between  pain  and  tenderness:  the  one 
denotes  the  existence  of  some  unusual  stimulus,  the  other  indicates 
increased  susceptibility  to  any  impression;  they  are  often  present 
together  in  various  conditions  of  disease  (e.  g.,  local  inflammations,) 
and  we  are  apt  to  consider  them  as  only  different  expressions  of 
the  same  nervous  phenomena.  When  they  are  taken  as  symptoms 
of  cerebral  disease,  and  when  no  local  cause  exists  in  the  part  in 
which  the  phenomenon  is  present,  it  is  still  more  important  to  re- 
member the  exact  idea  which  each  conveys:  the  one  is  to  be  re- 
garded as  perverted  sensation ;  the  other  as  morbid  sensibility. 

§  1.  General  Alterations  of  Sensibility. — General  tenderness  is 
not  a  symptom  of  much  consequence  when  standing  alone;  it  is 
then  commonly  the  result  of  hysteria,  or  mere  nervous  excitability: 
if  associated  with  causeless  anxiety,  depression,  or  dread,  or  with 
irascibility  of  temper  or  great  elevation  of  spirits,  it  points  to  in- 
sanity. 

Sensibility  generally  diminished  is  probably  never  seen  except  as 
the  result  of  mental  alienation,  or  as  combined  with  general  para- 
lysis ;  but  it  must  be  remembered  that  it  is  not  by  any  means  a 
necessary  concomitant  of  paralysis. 

Perverted  sensations  affecting  the  whole  system  are  similarly 
best  seen  in  cases  of  mental  delusion.  Analogous  phenomena  are 
observed  in  the  sensation  of  heat  complained  of  by  patients  in 
Asiatic  cholera,  while  the  whole  body  is  sensibly  cold ;  in  the  sen- 
sation of  chilliness  in  fever,  when  the  skin  is  morbidly  hot  to  the 
touch;  and  in  the  extreme  cold  and  shivering  of  ague,  or  of  severe 
rigor.  The  tjngling  and  formication  of  jaundice,  and  similar  sen- 
sations produced  by  the  action  of  certain  substances  in  peculiar 
idiosyncrasies,  are  scarcely  to  be  regarded  in  the  same  light.  The 
only  one  which  really  bears  on  our  present  subject  is  that  general 
sensation  of  pain  and  malaise  which  cannot  be  localized  by  the  pa- 
tient, and  is  not  to  be  accounted  for  by  the  condition  of  the  blood, 
as  in  fever:  this  symptom  is  not  to  be  lightly  disregarded,  and  is 
often  the  precursor  of  more  serious  lesions  of  the  nervous  system. 


ALTERATIONS    OF    SENSIBILITY.  143 

§  2.  Alterations  in  tfie  Sense  of  Sigjit. — Of  local  conditions, 
none  deserve  more  consideration  than  those  presented  by  trie  or- 
gans of  vision,  where  the  pupil  so  readily  exhibits  the  increased  or 
diminished  sensibility  of  the  retina,  independent  of  the  patient's 
volition.     They  consist  of — 

a.  Difference  of  size  of  the  pupils  on  either  side,  which  may  with 
certainty  be  regarded  as  evidence  of  severe  lesion  of  one-half  of 
the  brain:  it  usually  results  from  partial  or  complete  insensibility 
of  one  retina,  and  very  rarely  from  increased  susceptibility  or  irri- 
tability: in  the  majority  of  instances  it  is  a  dilatation  of  one  pupil, 
and  not  a  contraction  of  the  other. 

b.  Morbid  contraction  of  both  pupils ;  associated  either  with  (1) 
intolerance  of  light,  pointing  to  inflammatory  action;  or  (2)  with 
insensibility  more  or  less  marked,  especially  seen  in  coma  and 
narcotism;  or  (3)  simply  with  increased  irritability,  the  pupils 
dilating  pretty  freely  when  light  is  withdrawn,  but  contracting 
unduly  on  its  admission. 

c.  Morbid  dilatation  of  both  pupils :  (1)  with  insensibility  com- 
plete, indicating  pressure  equally  affecting  both  hemispheres,  and 
hence  most  commonly  seen  in  effusion  of  fluid  in  the  ventricles;  (2) 
with  oscillating  movements  when  light  is  withdrawn,  and  again 
suddenly  admitted — a  condition  most  commonly  found  in  the  tran- 
sition stage  from  inflammation  to  exudation  in  the  hydrocephalic 
forms  of  disease;  (3)  with  sluggish  movements,  which  only  show 
an  obtuseness  in  the  perception  of  light,  anil  the  excitement  of 
reflex  action,  the  pupil  dilating  largely,  and  contracting  feebly, 
when  light  is  withdrawn  and  again  admitted — a  common  condition 
in  fever;  (4)  a  similar  state  of  the  pupil  is  also  produced  by 
belladonna. 

Diktatiou  of  the  pupil,  with  insensibility  of  the  retina,  exists  in  amaurosis,  and 
the  distinction  between  blindness  resulting  from  disease  of  the  nerve,  and  that 
which  is  consequent,  on  disease  of  the  brain,  is  to  be  sought  in  other  symptoms  of 
disordered  innervation. 

The  point  to  be  studied  is  the  effect  of  the  sudden  admission  of  light  after  its 
exclusion.  When  no  change  at  all  occurs,  sight  is  lost,  whether  in  contraction 
or  dilatation;  but  the  movement  may  be  so  slight  as  to  escape  observation.  In 
contraction,  intolerance  of  light,  or  a  sense  of  pain  on  its  admission,  is  to  be  carefully 
noted;  in  dilatation  we  have  to  watch  for  evidence  of  the  existence  of  vision 
when  the  patient  is  unable  to  express  his  own  sensations. 

Increased  irritability,  seen  in  rapid  contraction  and  full  dilatation  on  the  admis- 
sion or  exclusion  of  light,  stands  exactly  opposed  to  sluggish  action :  the  one  in- 
dicates exalted,  the  other,  depressed  nervous  energy.  It  is  very  remarkable  how 
the  presence  of  some  object  producing  an  unusual  degree  of  attention  in  a  patient 
who  is  listless  and  depressed,  such,  for  instance,  as  the  entrance  of  a  friend  or 
near  relative,  may  immediately  restore  the  pupils  for  a  time  to  their  normal  ex- 
citability. In  examining  the  condition  of  the  pupil  it  is  of  the  greatest  impor- 
tance that  light  should  be  excluded  from  both  eyes  at  the  same  time,  in  order  to 
judge  correctly  of  the  effect  of  the  stimulus  upon  either  when  it  is  again  admit- 
ted. 

d.  Perversions  of  the  sense  of  vision  have  less  definite  relations 
to  conditions  of  brain.  The  most  important  are — (1)  double  vision, 
especially  when  not  associated  with  strabismus,  which  comes  more 


Ill  SEMEIOLOGyOFTIIEBRAIX. 

properly  under  the  head  of  muscular  movements;  (2)  dimness 
and  haziness  of  vision,  partial  loss  of  sight  when  a  portion  of  an 
object  is  lost,  and  seems  to  be  cut  off,  muscsc  volitantes,  and  ocular 
spectra;  (3)  hallucinations  and  illusions,  in  which  unreal  objects 
are  seen,  or  natural  objects  arc  clothed  in  unreal  shapes,  the  con- 
stant accompaniments  of  delirium.  The  first  division  is  that  which 
demands  the  most  attention,  as  being  probably  indicative  of  cere- 
bral disease:  the  whole  of  those  classed  in  the  second  division  are 
more  commonly  observed  in  sympathetic  or  functional  disturbance; 
the  third  are  the  results  of  delirium  or  mental  alienation ;  ocular 
spectra  are  distinguished  from  them  by  their  accompanying  states 
of  perfect  consciousness  and  reason,  when  the  evidence  of  the  other 
senses  proves  to  the  individual  the  non-existence  of  the  object. 

§  3.  Indications  derived  from  the  Sense  of  Bearing. — These  are 
much  less  numerous,  and  though  often  dependent  on  mere  local 
causes,  some  of  them  are  not  without  value. 

a.  Deafness  supervening  in  the  course  of  a  febrile  attack,  as 
indicating  diminished  sensibility  of  the  brain,  is  almost  certainly 
an  evidence  that  the  disease  is  fever  and  not  inflammation.  Ex- 
treme degrees  of  deafness  are  sometimes  produced  by  pressure. 

b.  Deafness  of  long  standing  in  a  person  suddenly  attacked  by 
febrile  disorder,  should  always  lead  to  inquiries  into  the  state  of 
the  ear.  Disease  located  there  is  very  apt  to  excite  inflammation 
within  the  cranium*,  it  is  commonly  accompanied  by  pain  and 
purulent  or  fetid  discharge.  For  the  same  reason,  when  pain  is 
present,  we  ought  to  inquire  into  the  existence  of  deafness,  or  any 
other  evidence  of  disease  ;  and  thus  a  history  of  scarlatina,  as  ante- 
cedent to  the  deafness,  is  very  instructive. 

c.  Intolerance  of  sound  or  noise  is  a  valuable  symptom  of  great 
nervous  irritability. 

d.  Less  importance  is  to  be  attached  to  the  existence  of  tinnitus 
aurium,  of  unnatural  sounds  and  noises,  or  voices.  The  former 
may  exist  along  with  disease  of  the  brain  ;  the  latter  are  more 
commonly  referrible  to  a  mental  state ;  but  both  are  not  unfre- 
quently  the  result  of  mere  local  affection. 

§  4.  Special  Alterations  of  Sensibility. — Perversion  and  loss  of 
the  senses  of  taste  and  smell  are  comparatively  unimportant  with 
reference  to  disease  of  the  brain;  they  are  generally  dependent 
on  some  morbid  condition  of  the  nerve  or  the  mucous  membrane. 
Alterations  of  common  sensation  in  other  organs  derive  their  chief 
significance  from  our  being  able  to  determine  whether  the  affection 
bo  limited  to  the  filamentous  extremities  of  the  nerves,  or  be  pro- 
duced by  some  cause  acting  upon  their  main  trunks,  or  be  con- 
nected with  disease  of  the  nervous  centres.  We  have  to  consider 
the  condition  of  the  parts  to  which  the  nerve  is  distributed,  and 
the  relation  of  the  affection  to  its  ramifications.  When  the  sensa- 
tion  is   referred   to   the  terminations  of  one  nerve,  we  have  to 


ALTERATIONS    OF    SENSIBILITY.  145 

observe  whether  any  perceptible  change  of  texture  in  the  organ  to 
which  it  is  distributed  can  account  for  its  existence;  when  no  such 
cause  exists,  we  have  to  inquire  whether  the  sensation  be  limited 
to  the  branches  of  that  nerve,  or  extend  to  others  having  a  similar 
origin.  Those  which  have  especial  reference  to  the  central  struc- 
tures, are  such  as  affect  the  entire  half  of  the  body,  or  extend 
equally  to  either  side:  those  limited  to  the  nerves  will  again  occupy 
our  attention  (see  Chap.  XVI. ;)  but  it  may  be  here  remarked,  that 
local  fixed  pain  often  accompanies  the  early  stages  of  chronic  dis- 
ease of  the  brain,  especially  in  organs  not  otherwise  the  subjects  of 
common  sensation.  It  may  be  quite  impossible  to  show  the  cause 
of  this  connexion,  and  the  fact  cannot,  therefore,  be  made  available 
for  the  purpose  of  diagnosis;  but  it  is  well  that  it  should  be  borne 
in  mind,  that  its  weight  may  not  be  lost  in  considering  other  symp- 
toms of  disease. 

Pain  of  the  head  and  giddiness  are  among  the  local  alterations 
of  sensibility  which  frequently  accompany  disease  of  the  brain, 
and  yet  they  are  the  least  to  be  relied  upon:  not  only  do  they  con- 
tinually fail  in  giving  notice  of  mischief  going  on  within  the  cra- 
nium, but  they  are  associated  with  so  many  other  disorders,  that  in 
by  far  the  greater  number  of  instances  they  do  not  point  to  any 
serious  lesion.  Thus  they  are  to  be  met  with  in  dyspepsia  and 
constipation,  and  in  almost  all  the  disorders  of  the  digestive  and 
assimilative  processes;  they  constantly  coexist  with  disorder  of  the 
circulation,  disease  of  the  heart,  anemia,  and  plethora,  whether  the 
head  be  too  freely  or  too  scantily  supplied  with  blood ;  they  are 
frequently  associated  with  altered  conditions  of  the  blood  itself,  in 
fever,  inflammation,  chronic  blood  ailments,  &c. 

These  belong  to  what  we  call  functional  disturbance  of  the  brain:  if  rightly 
considered,  they  ought  not  to  give  rise  to  any  important  misconception ;  for  in 
every  instance  the  organ  in  which  concomitant  symptoms  of  disorder  exist,  ono-ht 
to  be  carefully  examined.  For  example,  we  know  that  vomiting  and  constipatTon 
are  very  often  secondary  to  inflammation  of  the  brain;  and  if  for  a  momeut  this 
circumstance  be  forgotten,  and  the  attention  be  directed  only  to  the  local  derange- 
ment, we  find  nothing  there  sufficient  to  account  for  the  inflammatory  fever  which 
is  going  on;  the  tenderness  of  abdominal  inflammation  is  entirely  wanting:  on 
the  other  hand,  in  dyspeptic  headache,  however  intense  the  pain,  the  evidenced  in- 
flammation cannot  be  traced,  but  the  liability  to  disorder  of  the  stomach  is  a  fact 
easily  made  out.  Useful  information  may  be  obtained  in  cases  in  which  there  is 
a  possible  connexion  between  the  head  symptoms  and  disordered  circulation  or 
disease  of  blood,  by  inquiring  whether  the  pain  be  relieved  or  aggravated  by  as- 
suming the  horizontal  posture.  If  the  general  symptoms  be  only" those  of  fever, 
we  shall  have  more  difficulty  in  determining  whether  the  altered  sensibility  be 
caused  by  the  fever,  or  whether  it  point  to  some  more  serious  lesion,  and  ought 
to  teach  us  that  the  fever  itself  is  only  symptomatic. 

It  must  not  be  forgotten  that  the  pain  is  sometimes  external  to  the  skull ;  rheu- 
matic, with  tenderness  of  the  skin  and  rheumatism  in  other  parts;  inflammation 
of  the  scalp,  in  commencing  erysipelas  or  disease  of  bone,  inflamed  pericranium,  &c. 

In  all  the  functional  disorders  of  the  nervous  system  we  must  be  careful  neither 
too  hastily  to  conclude  that  they  are  limited  to  the  nerves  to  which  the  sensations 
are  referred,  nor  be  too  ready  to  ascribe  them  to  disease  of  the  central  organs  • 
there  are  no  such  cases  occurring  in  practice  which  are  not  occasionally  associated 
with  either  condition. 

10 


140  SEMEIOLOGY    OF    THE    BRAIN. 

Division  III. — Alterations  in  Muscular  Movement. 
Indications  derived  from  the  muscular  system  divide  themselves 
into  irregular  or  involuntary  movements,  and  loss  of  power: 
Bpasms,  convulsions,  and  palsy.  Some  of  these  conditions  have 
been  already  enumerated,  but  they  must  be  again  cited,  in  order  to 
contrast  them  with  those  which  are  essentially  connected  with  dis- 
ease of  the  brain:  they  belong  to  objective  phenomena,  and  are 
symptoms  which  can  hardly  escape  observation. 

§  1.  Spasmodic  Action. — The  slightest,  but  not  the  least  impor- 
tant form  of  this  affection  is  seen  in  the  muscular  twitchings  of 
fever,  as  subsultus:  it  is  at  first  only  indicated  by  a  tremulous 
movement  in  performing  any  voluntary  act,  caused  by  the  irregular 
action  of  the  muscles  combined  in  its  performance,  and  differing 
in  some  measure  from  the  tremor  of  mere  weakness  by  this  irregu- 
larity: in  a  further  stage  of  the  fever  it  is  more  constant,  and 
such  movements  of  the  muscles  of  the  arm  are  almost  always  seen : 
at  an  advanced  period  it  is  combined  with  delirium,  assuming  the 
character  of  "floccitatio,"  a  picking  at  the  bed-clothes,  performed 
in  this  tremulous  and  irregular  manner.  It  does  not  prove  that 
there  is  any  peculiarity  in  the  fever  poison,  but  only  that  the  brain 
and  nerves  are  especially  acted  upon  by  it.  Tremor  also  charac- 
terizes the  muscular  movement  in  delirium  tremens :  in  this  condi- 
tion there  is  less  irregularity  of  action,  and  every  motion  is  per- 
formed in  a  hurried  manner,  with  marked  energy  and  activity, 
while  in  fever  they  are  all  essentially  slow  and  apathetic. 

AVhen  the  muscular  twitchings  are  more  spasmodic  or  convulsive 
in  character,  and  there  is  delirium  or  loss  of  consciousness,  we  have 
reason  to  suspect  more  serious  mischief;  they  are  in  such  circum- 
stances often  confined  to  one  side  of  the  body,  or  more  marked  on 
one  than  on  the  other;  not  unfrequently  paralysis  of  one  side  is 
seen  associated  with  spasmodic  twitchings  of  the  other.  In  such 
affections  loss  of  control  over  the  movements  is  associated  with 
some  irritation  of  nerve-fibre  which  stimulates  the  muscles  to  action. 

Loss  of  voluntary  control  is  also  a  phenomenon  of  chorea,  in  the 
form  of  irregular  jactitation  of  the  whole  body,  of  the  various 
limbs,  or  only  of  one  of  them :  the  movements  are  more  spasmodic 
than  convulsive;  the  muscles  act,  not  simultaneously,  but  severally, 
in  opposition  to,  or  uncontrolled  by  volition.  The  absence  of  de- 
lirium or  stupor  in  this  instance,  proves  that  no  serious  lesion  of 
the  brain  exists,  and  leaves  it  undecided  in  what  part  of  the  ner- 
vous tracts  the  irritation  is  seated. 

General  convulsion  is  a  more  fearful  form  of  spasm :  the  muscles 
of  the  whole  body  are  thrown  into  violent  and  irresistible  contraction, 
which  produces  contortions  of  the  features  and  movements  of  the 
limbs;  volition  is  lost,  consciousness  is  suspended,  contraction  of 
one  set  of  muscles  is  immediately  followed  by  that  of  their  antago- 
nists, in  consequence  of  which  the  body  may  be  thrown  by  an 


ALTERATIONS    IN    MUSCULAR    MOVEMENT.       147 

almost  superhuman  strength  from  one  side  to  another;  the  feces, 
the  urine,  and  the  semen  are  often  involuntarily  evacuated.  Gene- 
ral convulsions  occur  in  various  forms  of  brain  disease,  but  attain 
their  greatest  severity  in  the  distressing  attacks  of  the  regular 
epileptic:  the  great  distinction  between  epilepsy  and  convulsion 
will  be  found  in  the  context  of  symptoms:  at  its  first  incursion,  the 
patient  attacked  with  epilepsy  seems  to  be  in  perfect  health  before 
his  seizure;  when  it  has  passed,  there  is  nothing  beyond  a  feeling 
of  languor  for  a  day  or  two,  or  muscular  soreness  from  violent 
action,  to  show  that  he  has  passed  through  the  struggle;  he  once 
more  appears  to  be  free  from  disease :  in  its  later  stages  the  history 
of  recurring  attacks  leaves  no  room  for  doubt.  When  dependent 
on  other  diseases,  convulsions  do  not  stand  alone,  but  are  found  in 
connexion  with  a  febrile  state,  with  delirium,  or  with  stupor  (see 
Chap.  XIIL,  §  5.) 

Children  are  particularly  liable  to  convulsions:  irritation  of  the 
nervous  system  is  with  them  very  apt  to  produce  the  affection,  and 
teething,  disordered  digestion,  or  intestinal  worms  are  its  common 
causes;  but  we  must  remember  that  it  is  not  unfrequently  the  first 
symptom  by  which  the  attention  of  parents  or  nurses  is  drawn  to 
the  existence  of  insidious  inflammation.  In  adults  there  is  gene- 
rally some  previous  history  when  convulsion  is  a  symptom  of  disease 
of  the  brain ;  still  it  does  occasionally  occur  as  the  first  manifesta- 
tion of  fatal  effusion  of  serum  in  the  ventricles,  in  consequence  of 
the  very  same  sort  of  inflammation  as  the  hydrocephalus  of  child- 
hood. Convulsion  is  also  a  very  usual  symptom  of  blood-poison- 
ing, in  cases  of  albuminuria. 

Spasm  is  the  prominent  feature  of  tetanus;  muscular  rigidity 
more  frequently  occurs1  in  connexion  with  disease  of  the  brain :  it 
sometimes  supervenes  on  paralysis,  causing  permanent  contraction, 
or  it  remains  as  a  consequence  of  convulsion,  especially  in  child- 
hood; in  other  instances  it  arises  slowly  and  spontaneously  in 
long-protracted  disease,  and  in  such  circumstances  it  must  be  re- 
garded as  a  serious  symptom. 

Strabismus  occasionally  exists  as  a  condition  of  muscular  spasm, 
but  is  more  commonly  due  to  paralysis.  It  is  one  of  the  incidents 
in  general  convulsion,  and  is  transient,  except  when  followed  by 
paralysis  of  the  antagonistic  muscle.  In  inflammation  within  the 
cranium  it  is  frequently  produced  by  irritation  of  the  origin  of  the 
motor  nerves,  and  is  then  a  very  common  cause  of  double  vision. 

§  2.  Paralysis,  as  a  symptom  of  disease  of  the  brain,  must  be 
studied  especially  with  relation  to  its  extent  and  duration,  and  also 
the  mode  of  its  incursion.  It  is  one  of  those  disorders  which,  in  a 
truly  scientific  classification,  could  find  no  place  except  as  a  symp- 
tom of  disease;  but  we  are  met  by  the  impossibility  of  ascertaining' 
the  exact  condition  of  the  nervous  structures  during  life,  and  we 
also  know  that,  while  it  is  dependent  on  a  great  variety  of  causes,. 


148  SEMEIOLOGY    OF   THE   BRAIN. 

its  features  present  characters  which  are  constant  and  invariable; 
thus  in  some  cases  we  cannot  get  beyond  the  fact  of  paralysis  being 
present,  while  in  others,  the  primary  cause  having  been  removed, 
the  function  of  the  muscles  only  remains  in  abeyance  until  they  are 
roused  by  the  repeated  application  of  some  local  stimulus.  It  has 
therefore  seemed  necessary  to  assign  to  it  a  separate  place  in  our 
classification  (see  Chap.  XV.,)  and  then  the  question  of  its  causes 
and  extent  will  be  more  fully  examined.  "VYc  may  here  remark 
that  paralysis  of  cranial  nerves  must  be  more  important  than  that 
of  solitary  nerves  in  any  other  part  of  the  body,  because  the  lesion 
is  so  much  the  more  likely  to  be  within  the  skull,  and  similarly, 
either  hemiplegia  or  paraplegia,  extending  to  the  nerves  origina- 
ting next  to  the  foramen  magnum,  i3  more  serious  than  when  either 
disease  is  limited  to  the  lower  limbs.  Again,  hemiplegia  is  more 
important  than  paraplegia,  because  the  two  hemispheres  of  the  brain 
are  more  distinct  than  the  two  halves  of  the  spinal  cord,  and  affec- 
tions of  one  side  are  therefore  more  likely  to  have  a  cranial  than  a 
spinal  origin. 

The  fact  of  the  paralysis  being  complete  or  incomplete,  does  not 
go  much  affect  the  situation  of  the  lesion  as  its  character,  and  is 
chiefly  of  importance  because  the  one  is  a  reality  about  which  there 
can  be  no  question,  while  the  other  may  either  be  overlooked  or  be 
simulated  by  diseased  imagination  or  perverted  will.  It  is  to  be 
remembered  that  we  are  only  dealing  now  with  one  symptom,  and 
if  we  are  to  attain  to  correct  diagnosis  we  must  compare  it  with 
the  other  evidence  of  cerebral  disease,  and  not  hastily  conclude 
that,  because  the  apparent  paralysis  is  such  as  might  have  a  cranial 
origin,  this  is  any  sufficient  ground  for  assuming  the  existence  of  a 
particular  form  of  disease. 

Ptosis  is  a  symptom  not  readily  to  be  passed  over:  difficulty  in 
articulation,  thickness  of  speech,  stammering  and  stuttering  or 
hesitation,  in  persons  who  have  had  no  such  previous  affection,  are 
also  of  much  importance  in  relation  to  disease  of  the  brain,  indi- 
cating, as  all  these  do,  some  affection  of  cranial  nerves.  Their 
anatomical  relations  may  help  us  to  trace  the  point  at  which  dis- 
eased action  is  going  on;  and  where  two  or  more  nerves  issuing  by 
different  foramina  are  simultaneously  affected,  we  have  at  least 
strong  presumptive  evidence  that  the  cause  of  the  paralysis  lies 
within  the  cranium. 

Strabismus  again  comes  under  consideration,  as  it  often  is  due  to 
paralysis.  We  have  to  inquire  whether  it  be  recent  or  of  old  stand- 
ing:  in  its  chronic  state  there  is  generally  retraction  of  one  muscle 
with  elongation  of  its  antagonist,  which  is  of  no  moment  as  a 
symptom  of  disease  now  going  on,  as  it  is  either  the  remnant  of 
some  convulsive  attack  in  childhood,  or  the  consequence  of  some 
defect  of  vision;  in  its  recent  state  it  is  very  frequently  the  evi- 
dence of  irritation  and  muscular  spasm,  but  is  also  occasionally 
seen  along  with  paralysis  of  other  cranial  nerves,  as  the  effect  of 
pressure,  e.  g.,  along  with  dilatation  of  the  corresponding  pupil. 


149 


CHAPTER  XIII. 

DISEASES    OF   THE   BRAIN. 

History — Acute  and  Chronic — Antecedent  States. — §  1,  Scrofulous 
or  Tubercular  Inflammation — In  Infancy — its  Early  Stage— its 
Advanced  Stage — In  Adults — its  Association  with  Phthisis — 
Tubercles  in  the  Brain — §  2,  Simple  Inflammation — its  Causes 
and  Characters — its  Locality — §  3,  Chronic  Disease — Distin- 
guished by  its  History  and  Symptoms — §  4,  Apoplexy — Charac- 
ters of  the  Fit — History — Partial  Coma — Serous  Apoplexy — 
Associations — §  5,  Epilepsy — Convulsion — its  Periodicity — Hys- 
terical Epilepsy — §  6,  Functional  Disturbance — its  Characters- 
Associated  with  Disease  in  other  Organs — with  General  Debility. 

In  the  preceding  chapter  a  general  outline  has  been  given  of  the 
very  large  class  of  symptoms  which  must  be  investigated  in  inquiring 
into  conditions  of  disease  in  the  brain,  and  at  first  sight  their  num- 
ber and  variety  seem  to  present  almost  insurmountable  difficulties; 
but  in  reality  it  is  not  so:  in  any  given  case,  we  are  rather  left  in 
the  dark  by  the  absence  of  trustworthy  evidence  of  the  state  of 
the  brain,  than  bewildered  by  the  number  of  objective  and  subjective 
phenomena:  thus,  when  the  mental  functions  are  deranged,  we  lose 
all  aid  to  be  derived  from  the  sensations  of  the  patient ;  in  some 
cases  one  symptom  (e.g.,  paralysis,)  stands  alone,  in  others  there  is 
scarcely  anything  to  indicate  the  existence  of  disease  beyond  the 
presence  of  pain,  which  we  know  may  be  exaggerated,  or  may  de- 
pend simply  on  disturbance  of  other  organs. 

We  cannot  too  often  recur  to  these  important  principles — (1)  to 
inquire  in  every  possible  way  into  the  history  of  the  case;  (2)  to 
examine  most  carefully  the  condition  of  other  organs,  and  search 
for  the  existence  of  other  diseases:  if  these  two  points  be  neglected, 
correct  diagnosis  is  almost  impossible ;  if  properly  attended  to,  they 
not  only  lead  us  in  the  right  direction  when  we  fail  to  get  at  the 
exact  truth,  but  they  also  enable  us  to  avoid  many  errors.  The  next 
step  is  to  consider  the  various  important  lesions  of  the  brain,  and 
ascertain  whether  the  case  under  investigation  adapt  itself  to  any 
one  of  these,  not  overlooking  the  possibility  of  insanity  and  simple 
functional  disturbance,  which,  with  all  their  complex  associations, 
belong  distinctly  to  diseases  of  the  brain. 

The  primary  division  is  into  those  with  and  those  without  a  febrile 
state.  Acute  diseases  of  the  encephalon  in  adults  seldom  arise 
spontaneously,  or  without  previous  derangement  of  health;  hence 
the  importance  of  the  history  of  the  case.  We  may  thus  be  enabled 
to  exclude  "head  symptoms"  occurring  in  the  course  of  some  other 


150  DISEASES    OF    THE    BRAIN. 

acute  disease ;  it  is  only  necessary  to  guard  against  being  misled  by 
a  vague  assertion  of  the  existence  of  fever,  when  this  was  but  the 
first  step  in  the  progress  of  inflammation.  The  history  also  conveys 
very,  important  information  with  reference  to  the  recurrence  of 
headache,  to  pain  or  discharge  from  the  ear,  to  previous  loss  of 
power,  or  attacks  of  convulsions  in  genuine  cases  of  disease  of  the 
brain,  or  to  cough  and  emaciation  as  preceding  tubercular  menin- 
gitis: in  either  case  inflammatory  action,  when  present,  is,  as  it 
were,  engrafted  on  old  standing  disease,  and  this  is  its  most  com- 
mon course ;  on  the  other  hand,  it  is  sometimes  developed  suddenly 
in  a  person  who  had  previously  enjoyed  perfect  health,  with  great 
febrile  disturbance,  severe  pain  in  the  head,  vomiting,  and  consti- 
pation ;  or  it  is  announced  in  a  more  unmistakeable  manner  by  the 
coexistence  of  convulsion.  Here  we  shall  learn  that  symptoms  of 
affection  of  the  brain  were  among  the  earliest  phenomena  of  disease, 
and  we  are  thus  assured  that  this' organ  has  not  become  secondarily 
affected  in  the  course  of  some  other  febrile  disorder. 

The  importance  of  the  information  obtained  from  this  preliminary 
inquiry  can  hardly  be  overrated,  in  so  far  as  it  serves  to  point  out 
the  association  of  the  tubercular  diathesis,  either  by  the  previous 
condition  of  the  patient  himself,  or  his  hereditary  tendency  to 
scrofula  or  consumption.  It  may  also  greatly  assist  us  in  forming 
a  judgment  as  to  the  exact  seat  of  the  disease,  whether  in  the 
membranes  or  in  the  substance  of  the  brain,  because  we  learn  from 
experience  that  meningitis  is  apt  to  be  produced  by  disease  of  bone 
in  the  internal  ear  and  the  sinuses  of  the  nares;  or  by  caries  or 
fracture  of  some  other  portion  of  the  skull ;  by  syphilitic  nodes  of 
the  pericranium,  or  by  injury  of  the  scalp,  especially  when  termi- 
nating in  suppuration;  on  the  other  hand,  inflammation  of  the 
substance  of  the  brain,  when  not  dependent  on  over-stimulation  of 
the  organ,  or  upon  scrofulous  deposit,  is  more  commonly  excited  by 
the  pressure  of  an  old  apoplectic  clot,  or  by  the  progress  of  chronic 
disease,  traces  of  which  are  to  be  found  very  often  in  the  past  his- 
tory of  the  individual. 

The  symptoms  in  the  acute  diseases  of  the  encephalon  are  not 
generally  such  as  point  with  any  distinctness  to  the  exact  site  of 
the  action,  because,  though  doubtless  commencing  in  different 
structures,  and  occasionally  limited  to  them,  inflammation  involves 
so  much  the  general  functions  of  the  brain,  as  the  centre  of  in- 
nervation and  the  organ  of  mind,  that  we  can  scarcely  assign  to 
each  part  a  distinct  share  in  their  production ;  it  rather  concerns  us 
to  find  out  any  really  available  mode  of  discriminating  the  two  great 
practical  divisions, — the  scrofulous  and  the  simple  inflammation. 

.  §  1.  Scrofulous  or  Tubercular  Inflammation.— This  form  of  in- 
flammation is  so  much  more  common  in  infancy  than  at  more 
advanced  periods,  that  until  recently  it  was  hardly  recognised  as 
occurring  after  the  age  of  puberty;  and  the  name  by  which  it  was 


SCROFULOUS    INFLAMMATION.  151 

first  known,  "acute  hydrocephalus,"  was  limited  to  childhood:  the 
records  of  St.  George's  Hospital  prove  that  it  is  not  uncommon  up 
to  the  age  of  twenty-five  or  thirty.  Its  symptoms  and  progress 
have  been  much  more  studied  in  the  earlier  periods ;  and  the  de- 
scription of  these,  in  consequence  of  the  modifications  due  to  vital 
phenomena  during  the  progress  of  development,  will  not  always  be 
found  applicable  to  the  disease  as  occurring  in  the  adult.  Patholo- 
gical research  seems  to  prove  that  the  disease  is  the  same,  at  what- 
ever age  it  occurs:  it  is  essentially  connected  with  the  strumous 
diathesis,  which  exerts  some  mysterious  agency  in  its  development, 
and  hence  it  is  numerically  far  more  common  than  simple  inflamma- 
tion: indeed,  up  to  the  age  of  twenty-five,  the  one  is  the  rule,  the 
other  the  exception ;  so  much  so  that,  excluding  infancy  altogether, 
the  number  of  cases  occurring  in  connexion  with  the  scrofulous 
diathesis,  from  eight  or  ten  years  of  age  onwards,  is  probably  double 
that  of  cases  of  simple  inflammation  at  all  periods  of  life  collec- 
tively: this  fact  is  very  important  in  diagnosis. 

The  tendency  of  the  inflammatory  action  is  to  the  effusion  of 
serum  rather  than  of  lymph  or  of  pus;  but  both  conditions  fre- 
quently coexist,  as  well  as  varying  degrees  of  softening  of  the  ce- 
rebral structures.  These  different  lesions  probably  correspond  to 
different  degrees  of  arterial  action  during  life,  as  indicated  by  heat 
and  pain  of  head,  in  opposition  to  dulness,  heaviness,  and  delirium ; 
at  present  no  certain  rules  can  be  laid  down  by  which  they  may 
be  discriminated:  coma  and  unconsciousness  are  pretty  certain  evi- 
dences of  effusion,  but  in  prolonged  cases  the  brain  seems  partly  to 
recover  its  power  and  become  tolerant  of  the  pressure.  The  sus- 
ceptibility of  the  brain  in  the  earlier  periods  of  life  is  so  much  greater 
than  in  later  years,  that  inflammation  of  the  brain  is  then  often  the 
first  indication  of  the  tubercular  diathesis,  while  afterwards  tuber- 
cular deposit  will  have  always  been  first  formed  in  other  organs. 

Much  as  has  been  written  on  the  diagnosis  of  the  early  stage  of 
this  disease  in  infancy,  it  is  practice  alone  that  can  give  any  readi- 
ness in  its  discrimination.  A  child  belonging  to  a  scrofulous  family 
is  attacked  by  slight  febrile  disorder,  with  irregularity  of  the  bowels, 
especially  tending  to  constipation,  with  vomiting  and  occasional 
fretfulness :  in  such  a  case  it  is  necessary  to  observe  very  carefully 
all  indications  referring  to  the  brain ;  the  mode  of  standing,  walk- 
ing, sitting,  lying,  any  aversion  to  light,  or  dislike  to  the  erect 
posture,  as  shown  by  nestling  its  head  on  the  mother's  bosom,  and 
turning  away  peevishly  from  any  attempt  to  amuse  or  occupy  its 
attention.  These  circumstances,  again,  must  be  compared  with  the 
amount  of  general  disturbance:  a  child  suffering  from  infantile 
fever  shows  much  more  weakness  and  prostration  in  comparison 
with  the  signs  of  cerebral  affection:  in  hydrocephalus  the  heat  of 
skin  is  most  marked  over  the  head,  but  is  not  in  proportion  to  the 
quickness  of  the  pulse ;  the  tongue  is  coated  but  not  dry ;  the  stools 
are  costive  and  often  deficient  in  bile;  thirst  is  not  urgent;  the 


152  DISEASES    OF   THE    BRAIN. 

vomiting  Las  no  necessary  connexion  with  the  period  of  taking 
food:  in  infantile  fever,  the  heat  of  skin  is  more  general,  there  is 
dryness  of  tongue,  thirst,  and  very  often  a  tendency  to  diarrhoea; 
listlessness  and  indifference  mark  the  expression  of  the  features 
rather  than  the  anxiety  and  knitting  of  the  eyebrows  so  often  seen 
in  hydrocephalus. 

In  simple  gastric  disorder,  on  the  other  hand,  there  is  little  or 
no  quickness  of  pulse,  no  heat  of  skin  or  of  head ;  the  tongue  is 
much  more  coated ;  the  vomiting  and  constipation  are  less  obstinate, 
yielding  more  readily  to  treatment;  the  countenance  may  be  dull 
and  inexpressive,  but  it  is  not  anxious. 

In  some  few  cases,  and  these  are  the  most  difficult  of  diagnosis, 
the  tubercular  disease  has  begun  so  decidedly  in  the  abdominal 
viscera,  that  diarrhoea  persists  till  the  head  affection  has  become 
unquestionable  from  the  presence  of  coma  or  convulsion:  in  other 
instances  an  attack  of  convulsion  is  the  first  circumstance  that 
awakens  the  attention  of  the  mother  or  nurse  to  anything  being 
wrong. 

The  hopelessness  of  the  disorder  deprives  diagnosis  of  much  of 
its  interest:  yet  it  is  well  to  be  able  to  warn  parents  of  approaching 
danger,  and  it  is  now  and  then  a  source  of  gratification  when  we 
can  remove  apprehension  regarding  a  case  which  has  been  looked 
upon  with  distrust,  and  can  feel  confidence  in  a  prospect  of  amelio- 
ration. 

In  the  advanced  stages,  extreme  listlessness  and  unwillingness  to 
be  moved,  frequent  moaning,  great  aversion  to  light  and  noise,  with 
marked  inequality  of  pulse,  followed  by  stupor,  convulsion,  para- 
lysis, strabismus,  or  insensibility  of  the  retinre,  and  total  blindness, 
sooner  or  later  make  the  nature  of  the  disease  only  too  evident: 
their  sequence  is  not  always  the  same,  and  the  more  decided  symp- 
toms may  be  postponed  till  within  a  day  or  two  of  the  patient's 
death.  When  the  disease  has  been  making  slow  and  insidious  pro- 
gress for  days  before  the  child  is  first  seen,  and  the  bowels  continue 
relaxed,  while  the  history  of  the  case  is  either  imperfect  or  incor- 
rect, it  is  apt  to  be  regarded  as  an  advanced  stage  of  fever:  this  is 
the  disease  with  which  in  all  circumstances  it  is  most  liable  to  be 
confounded,  and  therefore  a  few  hints  may  be  given  for  their  dis- 
crimination. In  doubtful  cases  it  is  always  a  favourable  sign  when 
the  child  is  seen  to  watch  the  attendant  as  a  stranger  in  the  room, 
when,  though  listless  and  unwilling  to  be  disturbed,  he  is  not  dis- 
tressed at  being  moved;  it  is  also  favourable  when  there  is  thirst 
and  no  refusal  of  fluid  nourishment;  and,  I  may  add,  what  seems 
paradoxical,  when  delirium  and  muttering  are  observed  at  night. 
This  is  explicable  enough  from  the  consideration  that,  if  delirium 
depended  on  serious  lesion  of  the  brain,  the  other  symptoms  would 
be  such  as  to  render  the  case  perfectly  clear ;  it  is  only  when  doubt 
exists  that  delirium  can  be  thus  viewed.  Deafness  may  be  to  a 
certain  extent  regarded  among  the  favourable  signs,  as  it  is  a  com- 


SCROFULOUS    INFLAMMATION.  153 

mon  circumstance  in  fever;  but  if  it  amount  to  total  loss  of  hearing, 
it  is  most  unquestionably  of  evil  omen.  Blindness  is  a  constant 
effect  of  effusion,  but  it  is  sometimes  difficult  to  make  out  whether 
the  child  be  blind  or  simply  indifferent  to  surrounding  objects:  mo- 
thers never  admit  the  fact,  and  the  mobility  of  the  pupil  can  alone 
be  taken  as  a  certain  guide. 

Heat  of  head,  refusal  of  fluids,  moaning,  anxiety  of  expression, 
are  all  unfavourable:  variableness  of  pulse  is  also  a  very  hopeless 
circumstance ;  its  acceleration  in  acute  hydrocephalus  is  constant, 
but  not  always  great,  often  less  than  in  fever,  sometimes  much 
greater;  its  occasional  increase  from  slight  causes,  as  "well  as  its 
unevenness  under  the  finger,  are  of  more  value  than  its  absolute 
frequency:   during  the  period  of  effusion  it  is  sometimes  slow. 

Hydrocephalus  must  be  carefully  discriminated  from  the  func- 
tional derangement  following  on  exhaustion,  which  often  so  closely 
simulates  it  as  to  have  received  the  name  of  the  hydrencephaloicl 
disease:  the  proper  place  for  its  consideration  is  among  functional 
disorders  (§  6;)  the  most  useful  diagnostic  mark,  in  cases  where  it 
remains  unclosed,  is  the  condition  of  the  fontanelle,  which  is  full 
and  tense  in  inflammation,  hollow  and  flaccid  in  exhaustion. 

In  adults  the  cases  of  tubercular  inflammation  of  the  brain  may 
be  divided  into  two  classes:  the  one  accompanying  the  early  stages 
of  tubercular  deposit,  when  miliary  tubercles  are  evenly  distributed 
through  the  lungs;  the  other  attending  the  advanced  stages  of 
phthisis,  with  vomicae  in  the  lungs.  In  their  general  features  there 
is  considerable  analogy,  but  in  the  early  cases  the  symptoms  are 
more  acute,  and  correspond  more  closely  to  those  seen  in  the  same 
disease  in  childhood;  in  the  advanced  cases  the  inflammation  is  of 
lower  type:  the  presence  of  disease  in  the  follicular  glands  of  the 
intestine  renders  constipation  very  rare;  vomiting,  on  the  other 
hand,  is  of  common  occurrence.  The  pulse,  so  often  quick  in 
phthisis,  is  always  so  in  this  affection  of  the  brain ;  the  head  is  hot 
and  painful;  night-sweats,  if  they  have  previously  occurred,  have 
ceased;  and,  contrary  to  what  is  found  in  childhood,  delirium  is  an 
early  symptom.  This  subject  has  been  already  fully  discussed 
under  the  head  of  delirium,  to  which  the  student  is  referred;  its 
presence  cannot  fail  to  draw  attention  to  the  condition  of  the  brain : 
it  may  be  accompanied  by  strabismus,  unequal  action  of  the  pupils, 
or  aversion  to  light  and  noise,  but  such  signs  are  more  often  want- 
ing among  adults.  Alterations  of  sensibility  and  mobility  are 
rarely  observed  in  the  early  stages. 

In  advanced  phthisis,  emaciation  naturally  leads  us  to  inquire 
into  the  previous  history,  especially  with  regard  to  chest  symptoms, 
if  none  such  have  been  detailed:  emaciation  unquestionably  also 
attends  chronic  disease  of  the  brain,  but  it  ought  to  be  enough  that 
a  suspicion  of  disease  of  the  lungs  is  suggested;  auscultation  can- 
not fail  to  reveal  its  existence  when  a  vomica  is  already  formed. 

In  early  phthisis,  with  equal  dissemination  of  tubercle  through 


154  DISEASES    OF    THE    BRAIN. 

the  lungs,  the  results  of  stethoscopic  examination  being  less  satis- 
factory, diagnosis  is  sometimes  at  fault.  The  disease  to  which  it 
bears  the  closest  resemblance  is  continued  fever  with  pulmonary 
congestion.  The  differences  in  the  auscultatory  signs  will  after- 
wards be  noticed  in  describing  diseases  of  the  chest,  but  sometimes 
they  cannot  wholly  be  relied  on  ;  and  even  when  they  are  well  defined, 
the  mind  is  so  apt  to  be  satisfied  with  the  explanation  which  "fever" 
affords,  that  careful  examination  is  forborne  in  the  depressed  and 
delirious  condition  of  the  patient.  In  such  circumstances,  a  correct 
history  serves  as  our  best  guide:  the  points  which  it  indicates  are 
the  existence  of  cough  before  the  commencement  of  the  present 
attack,  the  occurrence  of  both  headache  and  delirium  at  an  early 
period,  with  relation  to  the  fever  and  the  wandering  of  the  mind  by 
day  as  well  as  by  night.  In  conjunction  with  these  we  observe  the 
more  definite  symptoms  of  heat  of  head,  and  vomiting  with  a  tongue 
not  very  much  coated,  and  a  pulse  not  remarkably  quick  in  the  first 
instance,  but  often  variable  and  unequal. 

As  with  the  corresponding  disease  in  infancy,  the  result  of  diagnosis  is  very 
unsatisfactory,  revealing  only  the  hopeless  nature  of  the  malady.  Our  apprehen- 
sions, grave  at  any  time  when  the  brain  is  seriously  implicated,  assume  a  more 
gloomy  aspect  when  we  have  been  able  to  determine  that  tubercular  disease  is 
present  in  other  organs ;  nevertheless,  we  obtain  by  its  means  not  only  a  safer  guide 
to  treatment,  but  information  most  useful  in  the  varying  phases  of  the  disease, 
and  most  important  in  venturing  to  give  a  prognosis  to  the  friends  of  the  patient. 

It  has  been  stated  that  tubercular  inflammation  does  not  necessarily  imply  the 
presence  of  tubercles  in  the  brain  itself;  and  it  is  here  only  necessary  to  add.  that 
their  existence  is  not  generally  betrayed  by  any  symptoms,  even  when  found  of 
considerable  size  after  death,  till  inflammation  occurs;  and  the  course  of  the  dis- 
ease is  very  much  the  same  whether  there  be  tubercular  matter  in  the  brain  or 
not.  Even  when  we  have  evidence  of  previous  disease  of  the  brain,  and  we  may 
feel  justified  in  believing  that  it  is  caused  by  tubercular  deposit,  because  we  can 
trace  tubercle  more  or  less  clearly  in  other  organs,  still  its  'absolute  diagnosis  is 
quite  beyond  human  art.  Its  symptoms  do  not  differ  from  those  caused  by  the 
presence  of  any  other  morbid  growth. 

It  occasionally  happens  that,  after  an  acute  attack,  the  disease  lapses  into  a 
chronic  form,  consciousness  is  nearly  perfect,  but  paralysis  of  one  or  more  cranial 
nerves  remains,  with  less  distinct  evidence  of  general  cerebral  disturbance.  In 
such  cases  the  circumstance  of  previous  febrile  action,  along  with  local  lesion, 
points  pretty  definitely  to  the  coincidence  of  inflammation  and  tumour;  and  the 
probability  is  very  great,  in  the  case  of  children,  that  it  is  scrofulous  inflammation 
and  scrofulous  tubercle. 

§  2.  Simple  Inflammation. — Acute  simple  inflammation  of  the 
brain  is  exceedingly  rare  as  an  idiopathic  disease;  more  frequently 
it  is  set  up  by  injury  or  disease  of  bone,  and  now  and  then  acute 
symptoms  supervene  in  a  case  where  there  has  been  long-standing 
disease ;  in  all  of  these  the  general  characters  of  the  malady  are 
the  same,  and  the  history  can  alone  determine  its  cause  and  origin. 
The  important  antecedents  may  therefore  be  divided  into  two  classes : 
(1,)  those  which  have  reference  to  injury  or  disease  of  bone,  such, 
for  example  as  a  blow  or  fall,  tumours  or  abscesses  on  the  scalp, 
discharges  from  the  ears  and  nose,  or  deafness  from  disease  of  the 
ear;  and  (2,)  those  which  bear  more  especially  on  the  condition  of 


SIMPLE    INFLAMMATION.  155 

the  brain  itself — viz.,  the  occurrence  of  fits,  whether  apoplectic  or 
epileptic,  the  existence  of  any  form  of  paralysis,  impairment  of  vision, 
or  deafness  without  disease  of  the  ear.  These  circumstances  also 
tend  to  show  which  portion  of  the  encephalon  is  the  precise  seat  of 
inflammation;  but  the  determination  of  this  is  matter  rather  of 
curiosity  than  of  practical  importance  in  regard  to  treatment ;  it  is 
enough  for  our  purpose  if  we  can  determine  that  acute  inflamma- 
tion is  going  on  within  the  cranium. 

When  pronounced,  the  characters  of  the  disease  are  quite  un- 
mistakeable.  There  is  pain  of  the  head  and  restlessness,  followed 
by  quick,  hard  pulse,  hot  and  dry  skin,  white  tongue,  heat  of  head, 
and  flushing  of  face;  the  eyes  are  red  and  ferrety,  and  the  pupils 
contracted;  there  is  intolerance  of  light,  and  perhaps  of  noise;  there 
are  rigors,  nausea,  vomiting,  and  constipation,  followed  by  convul- 
sions, delirium,  coma.  Delirium,  strange  to  say,  is  often  absent,  or 
only  slight  and  transient,  until  a  semicomatose  state  follows  on 
convulsion ;  at  other  times  it  is  furious  and  maniacal. 

Pain  is  a  very  constant  symptom,  and  is  generally  referred  to  the  forehead,  but 
it  may  prove  a  very  fallacious  guide;  intense  headaches  find  their  solution  very 
often  in  simple  gastric  disorder:  the  pain  of  inflammation  is  sharp  and  darting, 
rather  than  aching,  and  when  associated  with  intolerance  of  light  and  noise,  we 
may  be  sure  that  it  is  something  more  than  mere  headache.  Heat  of  head,  flush- 
ing of  face,  pulsation  in  the  branches  of  the  external  carotid,  showing  increased 
action  there,  lead  to  the  belief  that  there  is  corresponding  increased  action  of  the 
internal  carotid,  caused  by  inflammation  within  the  cranium. 

The  nausea  and  vomiting  are  sometimes  very  striking;  the  smallest  portion  of 
food  or  drink  being  rejected,  and  sickness  continuing  even  when  nothing  is  taken 
into  the  stomach.  That  this  is  not  caused  by  gastric  inflammation  is  proved^  by  the 
absence  of  pain  and  tenderness  at  the  epigastrium  :  when  accompanied,  as  it  often 
is,  by  constipation,  we  have  to  bear  in  mind  that  this  condition  may  of  itself  cause 
sickness  and  great  cerebral  disturbance  in  cases  in  which  there  is  no  inflam- 
mation present.  The  diagnostic  value  of  such  symptoms  must  therefore,  in  the 
first  instance,  depend  on  their  being  associated  with  others  more  distinctly  referri- 
ble  to  the  brain  itself;  their  persistence  after  the  action  of  a  brisk  purgative,  of 
obstinate  slowness  of  the  bowels,  in  persons  not  habitually  costive,  are  not  to  be 
lightly  passed  over. 

Rigor  rarely  accompanies  the  onset  of  the  disease;  it  afterwards  occurs  fre- 
quently in  its  progress,  and  may  assume  such  a  character  of  periodicity  as  to  re- 
semble intermittent  fever,  and  lull  the  medical  attendant  into  fatal  security. 

Convulsions  appear  at  very  various  periods:  in  young  persons  they  sometimes 
usher  in  the  attack,  while  in  adults  they  are  more  generally  delayed  till  the  closing 
scene;  whensoever  they  exist  they  are  an  important,  and,  at  the  same  time,  an 
alarming  sign.  The  distinction  between  these  and  the  true  epileptic  seizure,  will 
be  afterwards  pointed  out  (see  \  5.)  The  symptoms  of  disease  do  not  remit,  after 
the  convulsive  seizure  has  passed,  in  true  inflammation  of  the  brain,  as  they  do  in 
epilepsy. 

Various  alterations  in  sensibility  and  mobility  succeed  to  the  exaltation  which 
first  accompanies  inflammatory  action;  and  the  progress  of  the  case  may  be 
marked  by  spasm  or  loss  of  power;  these  indicate  changes  in  cerebral  structure, 
or  pressure  from  effusion  of  lymph,  serum,  or  pus,  but  have  no  direct  bearing  on 
the  question  of  inflammation.  Strabismus  and  double  vision,  it  may  be  remarked, 
are  generally  the  first  in  this  sequence. 

The  presence  or  absence  of  delirium  seems  in  great  measure  to  depend  on  the 
portion  of  the  encephalon  attacked  by  inflammation.  It  can  scarcely  fail  to  be 
preseut  if  the  gray  matter  of  the  hemispheres  be  involved,  but  does  not  necessarily 
imply  this  particular  lesion.     In  character  it  very  much  resembles  an  attack  of 


156  DISEASES    OF    THE    BRAIN. 

acute  mania,  and  the  distinction  is  sometimes  not  easily  made  out.  Regard  must 
be  especially  bad  to  the  relation  the  delirium  bears  to  the  signs  of  increased  ac- 
tion, and  the  order  of  their  occurrence:  maniacal  excitement  necessarily  produces 
flashing  of  the  face  and  acceleration  of  the  pulse,  but  to  a  much  less  degree  than 
inflammation.  Evidence  may  also  perhaps  be  obtained  of  previous  perversion  of 
intellect  when  the  disorder  is  linked  with  insanity.  Constipation  is  common  to 
both  states,  and  there  will  be  little  chance  of  confounding  the  nausea  and  vomit- 
ing of  inflammation  with  the  refusal  of  food,  so  often  manifested  by  the  maniac. 
The  alleged  cause  of  the  attack,  whether  physical  or  mental,  may  sometimes  help 
our  diagnosis,  although  it  be  quite  true  that  a  purely  mental  one  may  excite  in- 
creased action  and  actual  inflammation,  as  well  as  mania.  The  occurrence  of 
convulsions  along  with  the  delirium  render  the  diagnosis  more  certain. 

The  extent  to  which  these  symptoms  are  present,  and  their 
number,  must  vary  much  in  different  cases.  Without  attempting 
to  go  too  minutely  into  the  diagnosis  of  the  particular  portion  of 
the  encephalon,  which  is  the  seat  of  disease,  it  may  be  observed 
that  pain  and  the  recurrence  of  rigor,  seem  rather  referrible  to 
inflammation  of  the  membranes  of  the  brain  generally,  while  con- 
vulsions point  to  that  more  immediately  investing  the  cerebral  mass 
— the  pia  mater  and  the  lining  membrane  of  the  ventricles;  deli- 
rium chiefly  accompanies  inflammation  of  the  gray  matter,  and 
alterations  in  sensibility  and  power  of  movement  have  especial 
reference  to  lesion  of  the  central  conducting  fibres  uniting  the  brain 
to  the  spinal  system.  Whether  it  be  that  the  exciting  cause  acts 
simultaneously  on  more  than  one  structure  from  the  first,  or  that 
inflammation  in  one  part  is  readily  transmissible  to  the  adjoining 
textures,  certain  it  is  that  we  seldom  find  local  and  circumscribed 
inflammatory  action  limited  to  any  one  tissue,  and  the  symptoms 
are  therefore  necessarily  more  or  less  ambiguous;  nay  more,  it  is 
even  true  that  those  belonging  more  especially  to  one  form  of  struc- 
ture may  be  excited  by  the  simple  proximity  of  inflammation  in 
another.  Xausea  and  vomiting  are  common  to  all  the  forms  of  in- 
flammation: they  are  to  be  more  carefully  noted  in  consequence  of 
their  occasional  occurrence  as  premonitory  symptoms,  which  must 
be  viewed  with  great  anxiety  in  persons  who  have  been  known  to 
suffer  from  discharge  from  the  ear,  or  to  have  had  any  other  of  the 
antecedents  of  cerebral  disease:  they  are  sufficient  to  cause  us  to 
be  on  the  alert  for  the  appearance  of  any  other  symptom  of  inflam- 
mation. Idiopathic  inflammation  of  the  membranes  and  particu- 
larly of  the  arachnoid  and  pia  mater,  is  much  more  frequent  in 
children  and  young  persons  than  in  adults;  in  them  its  first  symp- 
tom is  commonly  an  attack  of  convulsions:  inflammation  of  the 
substance  of  the  brain,  again,  is  the  more  usual  form  in  mature  age, 
generally  combined,  however,  with  meningitis.  From  this  combi- 
nation, no  doubt,  it  happens  that  the  course  of  the  symptoms  is 
seldom  the  same  in  any  two  individuals:  thus,  sudden  alteration  in 
manner  may  be  observed  passing  at  once  into  violent  delirium,  and 
followed  by  vomiting,  while  convulsion  occurs  only  at  a  later  period ; 
or  vomiting  and  pain  of  the  head  may  be  the  first  in  the  order  of 
sequence,  and  delirium  only  follow  towards  the  close  of  the  scene, 


CHRONIC    DISEASE.  157 

without  any  appearance  of  convulsion  at  all ;  or  again,  convulsions 
may  be  the  earliest  symptom,  but  I  believe  this  to  be  the  rarest 
mode  of  attack,  when  the  substance  of  the  brain  is  the  seat  of  the 
inflammation. 

In  all  of  these  cases  it  will  be  seen  how  little  we  can  rely  upon 
any  one  pathognomonic  sign,  and  that  if  we  would  avoid  dangerous 
or  even  fatal  errors  in  diagnosis,  regard  must  be  had  to  all  that  can 
be  learned  of  altered  function  or  action  in  disease. 

§  3.  Chronic  Disease. — If  the  diagnosis  of  acute  diseases  of  the 
encephalon  be  beset  with  difficulties,  those  encountered  in  investi- 
gating states  of  chronic  disease  are  still  greater,  and  in  the  majority 
of  cases  it  must  be  confessed  that  we  can  scarcely  form  any  certain 
opinion  as  to  the  actual  lesion ;  there  we  had  to  guard  against  being 
led  by  symptoms  referable  to  the  brain,  to  overlook  acute  diseases 
in  other  parts  to  which  they  were  only  secondary ;  here  we  are  very 
apt  to  mistake  mere  functional  disturbance  for  chronic  disease.  In 
a  practical  point  of  view,  and  this  is  the  most  important  one,  the 
only  question  of  real  interest  is,  whether  we  can  distinguish  such  as 
are  dependent  on  states  of  chronic  inflammation,  and  therefore 
remediable  in  a  majority  of  cases,  from  those  which  depend  upon 
other  causes,  when  we  must  be  content  with  treating  symptoms; 
because,  in  the  absence  of  inflammation,  the  same  broad  and  ra- 
tional principles  of  treatment  will  be  most  efficacious,  whether  they 
depend  upon  functional  disturbance  or  on  serious  disease. 

The  first  inquiry  is  necessarily  the  history  of  their  origin  and 
progress:  the  next  must  be  into  the  condition  of  all  the  other  organs 
of  the  body,  because  there  are  none,  it  may  be  said,  which  do  not 
occasionally  react  upon  the  brain ;  some,  it  is  true,  more  constantly 
than  others;  indeed  very  distinct  classes  of  symptoms  seem  to  be 
pretty  constantly  associated  with  particular  forms  of  disease,  while 
the  coincidence  in  other  cases  is  rather  accidental. 

If  we  fail  to  detect  disease  elsewhere,  we  must  again  revert  to 
the  brain  itself,  investigating  more  closely  the  relation  of  each 
phenomenon,  and  evidence  of  disease  of  bone  must  be  sought  for. 
The  presence  of  inflammatory  action  is  most  clearly  indicated  when 
the  commencement  of  the  attack  can  be  traced  back  to  a  fixed  and 
not  very  distant  period,  and  when  the  symptoms  follow  a  definite 
course :  uncertainty  with  reference  to  their  development  and  their 
irregularity  or  incongruity  are  to  be  taken  rather  as  indications  of 
insidious  disease,  or  of  nervous,  hysterical,  or  hypochondriacal  dis- 
orders. As  in  the  acute  forms,  careful  inquiry  must  be  made  re- 
garding previous  injuries  or  accidents,  and  the  presence  of  syphi- 
litic nodes  or  tumours  of  the  scalp ;  caries  and  suppuration  rather 
excite  acute  than  chronic  inflammation,  and  when  associated  with 
nervous  symptoms  of  long  standing,  are  more  commonly  found  to 
have  acted  through  the  medium  of  the  nerve-sheaths,  than  through 
the  brain  or  its  investing  membranes. 


158  DISEASES  OF  THE  BRAIN. 

After  careful  investigation  of  the  history  of  the  case,  the  other  attendant  cir- 
camstanci  8  are  to  be  considered.  A  cachectic  state  which  is  not  dependent  on 
discoverable  disease  in  other  organs  is,  to  a  certain  extent,  presumptive  proof  of 
organic  disease;  its  absence  is,  on  the  contrary,  an  argument  in  favour  of  chronic 

inflammation  where  disease  of  the  brain  is  believed  to  exist.  To  this  many  ex- 
ceptions are  found;  and  encysted  tumours,  for  example,  frequently  proceed  to  a 
fatal  termination  without  any  symptom  of  cachexia. 

Headache  more  or  less  accompanies  all  chronic  diseases  of  the  brain:  much  has 
been  written  on  this  subject,  but  little  is  known  with  certainty  beyond  the  fact  that 
cases  resembling  each  other  in  their  essence  may  differ  very  greatly  in  this  respect, 
while  those  producing  similar  sensations  of  pain,  weight,  aching,  or  dizziness,  may 
reveal  alter  death  lesions  very  unlike  one  another.  It  is  most  difficult  to  discri- 
minate cases  in  which  this  symptom  stands  alone  as  evidence  of  disease  of  the 
brain,  from  those  in  which  it  is  merely  secondary  on  deranged  digestion.  When 
dyspepsia,  vomiting,  or  constipation  coexists  with  headache,  the  determination 
must  rather  rest  on  the  absence  or  presence  of  concomitant  signs  than  on  its  in- 
tensity or  duration:  perhaps,  when  dependent  on  disease  of  the  brain,  the  pain  re- 
curs more  frequently,  and  without  chylopoietic  derangement;  the  intermissions  are 
less  frequent,  the  paroxysms  of  longer  duration;  it  is  aggravated  by  noise,  motion, 
light,  company,  and  is  never  dispelled,  like  a  dyspeptic  headache,  by  exercise  or 
excitement.  Very  often,  too,  the  recumbent  posture  aggravates  the  disorder;  but 
its  significance  is  greatest  when  it  is  accompanied  by  any  disturbance  of  the 
mental  faculties,  or  disorder,  however  slight,  in  the  performance  of  muscular 
movements. 

The  objective  phenomena  are  much  more  trustworthy  than  the  subjective.  Al- 
terations in  manner,  in  character,  or  in  memory — partial  paralysis,  whether  limit- 
ed to  one  or  more  of  the  cranial  nerves,  or  extending  in  a  modified  manner  to 
all  the  spinal  nerves,  or  to  those  on  one  side  of  the  body,  as  well  as  muscular  irri- 
tability or  spasm  similarly  distributed,  are  symptoms  which  can  be  more  readily 
brought  to  the  test  of  experiment  than  mere  complaints  of  pain  or  uneasiness. 
Mental  phenomena,  in  chronic  cases,  must  be  assumed  to  be  dependent  upon  some 
cause  of  pretty  general  action,  because  we  know  that,  in  the  absence  of  delirium, 
the  intellectual  faculties  are  frequently  undisturbed  by  lesions  of  very  consider- 
able extent,  especially  when  they  are  limited  to  one  hemisphere;  we  have  also 
reason  to  believe  that  the  gray  matter  of  the  convolutions  is  particularly  involved 
in  the  production  of  such  phenomena,  and  therefore  we  may  be  justified  in  re- 
garding them  as  evidence  of  chronic  meningitis.  When  the  cause  of  the  affec- 
tion is  central,  and  acting  secondarily  on  the  gray  matter,  we  shall  probably  find 
as  its  accompaniments  stupor  or  paralysis,  which  are  more  closely  connected  with 
disease  of  the  fibrous  element. 

Local  paralysis,  when  slight,  may  be  but  the  commencement  of  more  general 
paralysis;  when  complete,  it  rather  points  to  the  pressure  of  a  tumour,  or  to  some 
other  form  of  disease  of  local  character.  More  extended  paralysis,  if  caused  by 
pressure,  is  generally  accompanied  by  more  or  less  stupor  and  confusion  of 
thought;  when  standing  alone,  it  is  probably  dependent  on  disorganization  of  the 
central  structures  and  tubular  nerve  substance.  In  cases  in  which  it  is  less  pro- 
nounced, it  would  seem  sometimes  to  be  caused  by  chronic  inflammation  of  the 
membranes,  especially  about  the  base  of  the  brain.  Paralysis,  coma,  and  convul- 
sion, with  reference  to  all  forms  of  chronic  disease  of  the  brain,  are  symptoms  of 
very  unfavourable  omen;  spasm,  or  imperfect  control  of  movement,  hold  out  more 
hope  of  possible  amelioration,  as  they  rather  show  some  inflammatory  action  or 
irritation  of  nerve  matter.  Convulsion  is  not  often  seen  in  chronic  disease  till  to- 
wards its  termination;  it  generally  indicates  some  degree  of  inflammation  extend- 
ing to  the  ventricles  or  the  base  of  the  brain. 

Not  un frequently  cases  of  long-standing  disease  put  on,  at  some  period  of  their 
history,  the  aspect  of  active  inflammation.  The  acute  symptoms  in  such  circum- 
stances may  be  somewhat  modified  by  the  previous  disease,  but  their  diagnosis  is 
much  facilitated  by  a  knowledge  of  the  foregoing  state.  Unfortunately,  the  prog- 
nosis is  almost  hopeless,  the  chances  of  modifying  the  course  of  the  inflammatory 
action  being  so  much  the  smaller  in  proportion  to  the  severity  of  the  organic  lesion 
out  of  which  they  have  sprung. 


APOPLEXY.  159 

Symptoms  of  chronic  disease  are  sometimes  due  to  degeneration  of  the  coats  of 
the  arteries  of  the  brain,  and  a  hint  of  this  possible  contingency  may  be  obtained 
from  the  presence  of  valvular  disease  of  the  heart  which  cannot  be  traced  to  an 
inflammatory  origin. 

§  4.  Apoplexy. — No  condition  of  disease  is  probably  more  marked 
or  more  easily  recognised  than  a  pure  case  of  apoplectic  seizure. 
Suddenly,  while  to  appearance  in  perfect  health,  the  patient  loses 
recollection,  and  falls  to  the  ground  in  a  state  of  unconsciousness; 
his  face  is  turgid;  his  temples  throb;  his  eyeballs  turn  upwards;  his 
features  are  drawn  to  one  side ;  slight  convulsive  tremor  agitates  his 
frame,  usually  on  one  .side;  and  he  lies  dead  to  all  around  him. 
When  examined,  probably  one  side  of  his  body,  or  even  the  whole 
of  his  limbs,  have  become  flaccid  and  useless,  remain  in  any  posture 
in  which  they  are  placed,  and  drop  as  lifeless  things  when  lifted 
from  the  couch ;  his  breathing  is  slow  and  laboured ;  his  pulse  op- 
pressed, small,  and  yet  resisting;  if  one  side  only  be  paralyzed,  he 
makes  meaningless,  purposeless  efforts,  and  struggles  with  the  limbs 
of  the  other,  when  any  attempt  to  move  him  is  made;  in  course  of 
time  his  breathing  becomes  stertorous;  his  urine  is  retained  in  the 
bladder,  or  dribbles  away  in  the  bed;  his  feces  are  passed  involun- 
tarily. Without  another  conscious  movement,  without  any  know- 
ledge of  what  has  transpired,  the  coma  deepens,  the  breathing  be- 
comes a  succession  of  interrupted  sighs,  and  he  passes  away  with- 
out a  struggle. 

Clear  and  unmistakeable  as  such  a  case  is,  we  find  in  practice 
that  all  the  symptoms  may  be  so  shaded  off  by  imperceptible  differ- 
ences, that  at  length  scarcely  any  portion  of  the  original  picture 
remains,  by  which  to  give  an  exact  definition  of  an  attack  of  apo- 
plexy; and  in  common  parlance,  a  "fit,"  followed  by  loss  of  con- 
sciousness, is  called  apoplexy.  This  is  not  the  place  to  discuss 
whether  anything  be  rightly  called  apoplexy  which  is  not  distinctly 
traceable  to  turgidity  of  vessels,  with  or  without  their  rupture,  and 
the  consequent  extravasation  of  blood;  but,  as  a  matter  of  diagnosis, 
it  is  essential  to  distinguish  sanguineous  apoplexy  from  all  other 
sorts  of  "fit,"  whether  these  be  followed  by  loss  of  consciousness 
or  not. 

"When  a  history  can  be  obtained  in  a  case  of  apoplexy,  it  is  not 
unusual  to  find  that  there  have  been,  for  some  days  or  weeks,  occa- 
sional warnings,  which  are  spoken  of  as  "tendency  of  blood  to  the 
head,"  consisting  of  headache,  giddiness  on  sudden  change  of  pos- 
ture, throbbing  of  the  temples,  &c. ;  and  the  occasion  of  the  fit  it- 
self has  been  some  strain  or  prolonged  muscular  effort,  or  some 
mental  excitement.  The  fit  itself  may  not  be  the  first  step  in  the 
actual  progress  of  the  malady,  but  may  be  preceded  for  some  hours 
by  an  accession  of  violent  pain,  or  by  some  form  of  paralysis  of  the 
cerebral  or  even  of  the  spinal  nerves.  The  occurrence  of  apoplexy 
is  generally,  to  a  certain  extent,  limited  by  age;  a  full  habit  of  body, 
luxurious  living,  turgescence  of  the  face,  and  the  cessation  of  habi- 


1G0  DISEASES    OF    THE    BRAIN. 

tual  dis charges,  may  each  be  found  among  the  precursors,  or,  as 
tiny  arc  called,  the  predisposing  causes  of  apoplexy. 

It  has  been  already  remarked,  in  speaking  of  semicoma,  that  it 
may  be  equally  associated  with  apoplexy  and  with  epilepsy;  and  in 
the  broad  outline  of  the  former,  just  given,  a  drawing  of  the  face 
to  one  side,  and  convulsive  movements  of  the  whole  or  part  of  the 
frame,  have  been  mentioned  as  noticeable  in  an  unquestionable  case 
of  apoplexy;  and  therefore  it  is  evident  that  the  "fit,"  and  the 
semicoma  following,  may  be  symptomatic  of  either  disease;  in  fact, 
it  resolves  itself  into  a  question  of  degree,  the  amount  of  convul- 
sion, the  depth  of  coma.  Apoplectic  convulsion  is  rather  a  faint 
tremor  than  convulsion,  and  is  most  marked  when  paralysis  of  one 
side  of  the  face  leads  to  more  distinct  deviation  to  the  other.  In 
epileptic  convulsion,  however  slight,  there  is  definite  movement, 
forcible  and  almost  irresistible,  distinctly  dragging  the  limb  or, the 
head  into  unnatural  contortions,  and  these  are  rarely  limited  to  one 
side.  The  physician  has  no  chance  in  general  of  seeing  the  move- 
ment and  judging  for  himself,  but  any  intelligent  by-stander  can 
comprehend  the  difference  and  say  what  he  saw.  Then,  again,  the 
coma  differs  in  degree,  and  in  the  opposite  direction:  if  the  con- 
vulsion of  apoplexy  be  slighter,  the  coma  is  deeper.  The'difference 
can  scarcely  be  made  intelligible  by  words,  but  the  loss  of  con- 
sciousness and  usual  sleep  of  epilepsy  are  quite  distinct  from  the 
stupor  of  apoplexy:  the  one  consists  rather  in  confusion,  the  other, 
in  suspension  of  the  mental  faculties. 

But  there  is  another  condition,  which  is  called  serous  apoplexy. 
Here,  too,  there  is  a  fit:  there  is  loss  of  consciousness  and  paralysis, 
and  yet  there  has  been  no  turgidity,  no  rupture  of  vessels — mere 
effusion  of  serum.  This  fact  has  been  alreadv  referred  to,  and  it 
is  almost  incredible  that  it  should  take  place  instantaneously.  I 
think  we  must  believe  that  a  morbid  process  has  been  going  on  for 
some  time;  that  at  a  certain  point  the  brain  becomes  intolerant  of 
pressure,  this  point  being  determined  by  momentary  repletion  of 
either  arteries  or  veins,  or  of  the  capillary  vessels,  and  that  then 
the  event  occurs  in  a  moment.  This  is  not  true  apoplexy,  and 
careful  inquiry  will  always  show  that  it  is  more  nearly  allied  to 
epilepsy;  that  it  is,  in  fact,  analogous  to  the  convulsive  seizure 
which  ushers  in  hydrocephalus,  even  in  the  adult;  but  the  paralysis 
has  proved  the  stumbling-block,  and  has  been  thought  distinctive 
of  apoplexy.  The  diagnosis  is  difficult,  but  I  can  affirm,  from  per- 
sonal experience,  that  it  is  not  impossible,  though  perhaps  nothing 
can  teach  it  except  watching  such  cases,  with  the  knowledge  that 
events  of  this  nature  do  occur,  and  that  they  do  manifest  them- 
selves by  special  features. 

The  condition  of  the  pupils  deserves  consideration,  although  no 
very  definite  rules  can  be  laid  down.  Contraction  indicates  irrita- 
tion ;  dilatation,  paralysis  of  the  optic  nerve.  A  want  of  corre- 
spondence between  the  two  proves  the  existence  of  more  severe 


APOPLEXY.  161 

lesion  on  one  side  than  the  other;  and  would,  therefore,  at  once 
exclude  the  idea  of  epilepsy. 

Be  it  remembered,  that  there  is  no  one  symptom  by  itself  dis- 
tinctive of  sanguineous  apoplexy,  and  it  is  often  only  after  several 
examinations  that  a  diagnosis  can  with  confidence  be  pronounced. 
There  are  two  points  which,  in  the  subsecpient  condition  of  the 
patient,  serve  very  greatly  to  discriminate  the  cases ;  these  are,  the 
recurrence  of  the  "fits,"  and  the  relative  consciousness  on  succeed- 
ing days.  (1)  When  they  recur  at  short  intervals,  and  no  paralysis 
follows,  the  case  is  certainly  not  sanguineous  apoplexy;  even  if  the 
convulsive  movements  be  only  slightly  marked,  they  are  probably 
epileptic,  and  after  their  cessation,  convalescence  from  the  condition 
of  coma  may  be  confidently  looked  for.  When  recurring  at  longer 
intervals,  sometimes  of  days,  more  often  of  weeks,  with  paralysis 
enduring  throughout,  it  is  probably  an  instance  of  serous  apoplexy ; 
true  sanguineous  apoplexy  only  recurs  at  very  much  longer  inter- 
vals. (2)  Alike  in  epilepsy  and  in  serous  apoplexy,  consciousness 
is  not  so  entirely  suspended  as  in  sanguineous  apoplexy;  at  least, 
it  is  so  for  a  much  shorter  time ;  when  serai-coma  follows  upon  epi- 
lepsy, the  subsequent  state  is  one  of  prolonged  sopor,  from  which, 
when  the  patient  is  roused,  he  manifests  a  certain  degree  of  con- 
sciousness by  placing  himself  comfortably  in  bed,  drawing  up  the 
clothes,  &c. ;  but  no  regard  is  paid  to  surrounding  objects.  In 
serous  apoplexy  the  sopor  is  less  prolonged,  and  it  is  followed  by  a 
kind  of  vague,  dreamy  consciousness,  which  is  attracted  by  sur- 
rounding objects,  without  recognising  or  understanding  them,  so 
that  the  impression  made  on  the  senses  is  not  followed  by  any 
corresponding  rational  act.  In  apoplexy  the  patient  wakes  as  from 
profound  sleep,  and  the  recollection  is  confused,  the  thoughts  are 
collected  with  difficulty,  and  the  reason  used  imperfectly;  but  there 
is  distinct  consciousness  in  the  waking  movements. 

The  character  of  the  pulse  in  cases  of  apoplexy  is  one  which  demands  careful 
study  on  the  part  of  the  practitioner,  because  of  its  bearing  on  the  all-important 
question  of  venesection  :  it  has  also  its  uses  in  diagnosis,  inasmuch  as  a  hard, 
wiry  pulse,  or  a  condition  of  vascular  congestion  about  the  head  and  throbbing  of 
the  temporal  arteries,  are  so  many  indications  of  sanguineous  apoplexy;  but  the 
converse  does  not  by  any  means  exclude  the  possibility  of  rupture  of  a  blood- 
vessel. 

In  all  of  these  sudden  invasions  of  the  intellect,  the  heart  and  kidneys  must  be 
closely  examined.  Few  cases  of  fatal  sanguineous  apoplexy  occur  in  which  both 
organs  do  not  present  evidence  of  disease,  and  probably  in  all  cases  one  or  other 
is  at  fault.  Serous  apoplexy  is  perhaps  more  frequently  associated  with  the  stru- 
mous diathesis;  one  form  of  convulsive  seizure  is  directly  connected  with  blood- 
poisoning  in  disease  of  the  kidney,  and  it  is  perhaps  conjoined  with  effusion  of 
serum.  To  another  condition  attention  has  been  drawn  of  late  years — viz.,  the 
washing  down  in  the  current  of  the  blood  of  some  vegetation  which  has  been 
gradually  growing  on  the  valves  of  the  heart;  this  is  suddenly  arrested  in  some 
of  the  small  arteries  of  the  brain,  stopping  the  supply  of  blood  to  the  parts 
beyond,  and  interfering  with  their  nutrition.  In  consequence  of  such  an  acci- 
dent, paralysis  may  either  supervene  rapidly  when  deficient  supply  is  sufficient  to 
produce  it,  or  may  come  on  gradually  when  imperfect  nutrition  has  led  to  dis- 

11 


102  DISEASES    OF    TIIE    ERAIN. 

nizatioo  of  ]>art  of  the  brain-structure.    Iu  either  case  the  menial  phenomena 
■       .  &c,  are  generally  wanting;  and  tins  may  .serve,  along  with 

physical  evidence  of  valvular  lesion,  to  lead  to  a  pretty  correct  guess  at  its 
can 

5.  Epilepsy. — Epileptic  convulsions  have  been  frequently  re- 
ferred to,  yet  something  remains  to  be  added  to  give  consistency  to 
its  diagnosis.  The  term  is  somewhat  indefinite  in  its  application, 
because  while  on  the  one  hand  it  is  used  to  denominate  a  specific 
disease  which  has  no  analogue  in,  and  receives  no  explanation  from 
any  of  the  disorders  of  function  to  which  the  brain  is  liable,  yet  on 
the  other  hand  it  is  applied  more  or  less  indefinitely  to  any  sudden 
seizure  which  is  marked  by  convulsions  and  loss  of  consciousness. 

The  grand  distinction  between  epilepsy  and  convulsion  is  to  be 
derived  not  from  any  peculiarity  in  the  seizure,  but  from  the  context 
of  symptoms.  It  resolves  itself  into  the  question,  is  there  any  dis- 
ease present  in  any  organ,  in  the  course  of  which  convulsions  may 
and  do  occur?  On  this  question  being  answered  in  the  negative 
depends  the  diagnosis  of  true  epilepsy,  imperfect  as  it  must  be 
confessed  that  such  a  distinction  is.  This  point  is  quite  unconnected 
with  its  curability:  the  prevailing  theory  at  present  is,  that  the 
eeizure  consists  in  an  excess  of  irritability  and  over-excitement  of 
the  nervous  centres ;  in  curable  cases,  certain  concomitant  conditions, 
are  regarded  as  sources  of  irritation,  and  these  being  removed,  and 
the  tone  of  the  nerve-fibre  itself  restored,  the  disease  ceases.  The 
question  proposed  is  not  whether  there  be  any  such  circumstance 
which  determines  the  attack,  but  whether  disease  be  present,  which, 
either  by  being  seated  in  the  brain  itself,  or  by  establishing  a  cer- 
tain blood-crasis,  tends  directly  to  produce  convulsions  during  its 
continuance.  The  most  notable  examples  are  inflammations  of  the 
cerebro-spinal  axis,  puerperal  states,  and  albuminuria,  or  more  pro- 
perly, perhaps,  urajmia.  In  true  epilepsy  we  fail  to  detect  any 
s  ich  conditions  during  life,  and  although  we  do  find,  in  certain  cases 
after  death,  something  within  the  cranium  which  may  have  acted 
a^  a  permanent  cause  of  irritation,  its  mode  of  action  is  unknown; 
it ^  symptoms  are  limited  to  the  simple  expression  of  irritability  in 
the  epileptic  seizure. 

The  convulsions  of  childhood  may  be  said  to  form  a  class  by 
themselves:  more  nearly  allied  to  epilepsy  than  to  the  secondary 
convulsions  of  adults,  they  seem  to  depend  on  a  species  of  excita- 
bility which  is  probably  owing  to  the  disproportionate  development 
of  the  brain  of  infancy;  as  in  epilepsy,  too,  the  sources  of  irritation 
are  various;  with  the  exception  of  those  connected  with  inflamma- 
tion, they  do  not  lie  within  the  cranium;  but  while  one  child  never 
shows  the  slightest  tendency  to  convulsion,  another  suffers  repeated 
attacks  from  all  the  accidents  of  infancy;  teething,  worms,  intes- 
tinal disorder,  or  mere  exposure.  Still  they  are  not  to  be  called 
epilepsy,  except  they  return  periodically,  without  the  presence  of 
the  exciting  cause;  that  in  some  children  repeated  convulsions 
terminate  in  confirmed  epilepsy  is  too  true,  but  in  by  far  the  greater 
number,  fortunately,  no  such  lamentable  occurrence  results. 


EPILEPSY.  163 

One  great  element  in  epilepsy  is  its  periodicity,  whether  regular 
or  irregular ;  but  the  first  recurrence  may  be  at  so  long  an  interval 
that  the  patient  is  lost  sight  of  before  a  second  fit  occurs,  and  our 
diagnosis  cannot  wait  for  such  an  event  for  its  confirmation.  Its 
importance  is  such,  however,  that  in  all  convulsive  attacks  it  is  de- 
sirable to  ascertain  from  friends,  or  from  the  patient  himself,  as 
soon  as  consciousness  is  restored,  whether  he  have  ever  been  at  all 
similarly  afflicted. 

The  severity  and  duration  of  the  attack  vary  very  greatly,  from 
a  transient  loss  of  consciousness  with  the  slightest  possible  muscular 
spasm,  to  the  most  violent  and  horrible  convulsions.  In  the  former 
case  the  patient  is  arrested  for  a  moment  or  two  in  his  usual  avoca- 
tion, retains  his  position  without  falling,  whether  standing  or  sitting, 
and  proceeds  with  his -work  as  if  nothing  had  happened.  In  the 
latter,  the  mind  remains  confused  when  consciousness  is  restored, 
and  the  patient  soon  falls  asleep,  to  wake  up  generally  in  a  short 
time,  stiff',  or  sore,  or  bruised,  and  perhaps  complaining  of  head- 
ache, but  not  otherwise  feeling  ill.  This  confusion  of  mind  and 
tendency  to  sleep  is  in  rare  instances  prolonged  for  some  days,  the 
patient  remaining,  as  has  been  already  pointed  out,  in  a  semicoma- 
tose state. 

The  diagnosis  between  true  epilepsy  and  convulsions  arising  from  other  causes 
is  not  to  be  regarded  as  a  matter  of  merely  curious  investigation,  for  upon  its  just 
appreciation  depends  the  correct  treatment  of  the  case.  I  may  cite  an  example 
in  which  the  first  epileptiform  seizure  was  accompanied  by  some  delirium,  which 
differed  materially  from  the  mere  confusion  of  epilepsy ;  but  the  whole  disorder 
seemed  so  transient,  that  its  peculiarities  were  attributed  to  manifest  bad  manage- 
ment in  the  commencement  of  the  attack;  and  with  some  misgiving  it  was  re- 
garded as  epilepsy.  The  patient  was  dismissed  as  having  recovered  ;  but  the  next 
attack  was  distinctly  one  of  serous  apoplexy,  at  an  interval,  indeed,  of  nearly  two 
years.  After  death  there  was  found  immense  dilatation  of  one  of  the  lateral  ven- 
tricles. I  cannot  doubt  that  in  this  case  a  condition  of  chronic  inflammation  had 
existed  throughout,  and  that  judicious  treatment  might  possibly  have  prevented 
the  fatal  termination. 

An  epileptic  seizure  may  be  either  feigned  for  the  purposes  of  deception,  or  simu- 
lated by  the  hysterical  paroxysm.  One  grand  source  of  distinction  in  such  cases 
is  the  circumstance  of  no  corporeal  injury  being  inflicted  during  the  attack:  not 
that  this  necessarily  happens  in  true  epilepsy;  but  while,  on  the  one  hand,  a  bitten 
and  bleeding  tongue  or  a  bruised  face  may  be  taken  as  conclusive  evidence  of  ge- 
nuine convulsion,  its  avoidance  in  circumstances  which  might  naturally  have 
given  rise  to  it,  leads  to  the  suspicion  that  consciousness  has  not  been  entirely 
lost.  The  determination  of  its  nature,  indeed,  turns  mainly  on  the  existence  of 
consciousness,  and  various  methods  must  sometimes  be  had  recourse  to  for  the 
purpose  of  ascertaining  it.  There  is  generally,  too,  a  certain  method  and  regu- 
larity in  those  movements  which  are  either  partially  or  wholly  voluntary;  and  in 
the  case  of  hysterical  females,  other  characteristics  may  be  observed  from  which 
the  prevalence  of  hysteria  may  be  predicated,  and  the  consequent  probability  that 
the  seizure,  is  only  part  of  the  same  disorder.  But  this  demands  experience  and 
attention  rather  than  book-learning. 

Certain  points  must  not  be  omitted  in  the  investigation  of  convulsive  attacks 
which  are  not  immediately  connected  with  diagnosis.  In  a  first  seizure,  it  has 
been  shown  how  necessary  is  the  incpiiry  into  the  condition  of  other  organs;  but 
it  is  no  less  so  even  in  cases  where  periodicity  is  clearly  established.  The  possi- 
bility of  success_in  the  treatment  of  all  such  disorders  depends  upon  the  correct- 


164  DISEASES    OF    THE    BRAIN. 

ness  of  this  information,  and  in  proportion  to  its  accuracy  will  their  management 
be  removed  from  the  realm  of  empiricism,  and  come  under  the  domain  of  legiti- 
mate medicine.  Not  only  do  the  physical  condition  of  the  cranium  and  all  the 
relations  of  the  brain  to  sensation,  motion,  and  the  intellectual  faculties,  demand 
particular  study;  but  respiration,  circulation,  digestion,  and  elimination,  have  each 
been  proved  to  have  their  influence,  if  not  as  causes  of  the  disease,  yet  as  special 
sources  of  irritation,  and  therefore  must  each  be  individually  inquired  into;  and  if 
last,  not  least,  the  reproductive  organs,  in  their  changes  from  disease  to  health, 
from  imperfection  to  maturity,  exercise  a  most  unquestionable  influence  over  its 
amelioration  and  its  cure. 

§  6.  Functional  Disturbance. — Vague  as  this  terra  may  be,  it 
needs  no  argument  to  show  the  necessity  for  such  a  distinction  in  a 
classification  of  nervous  diseases.  Not  only  do  our  present  means 
of  investigation  fail  in  pointing  out  that  there  is  any  disease  in  nerve- 
structure  accompanying  the  delirium  of  fever,  or  puerperal  mania; 
but  there  are  numerous  slighter  and  more  transient  alterations  in 
the  relations  of  the  brain  as  the  recipient  of  sensation,  the  origina- 
tor of  motion,  and  the  medium  of  intellectual  operations,  the  nature 
of  which,  were  our  means  of  investigation  never  so  perfect,  we 
cannot  by  any  possibility  have  the  opportunity  of  ascertaining 
through  the  bony  wall  of  the  cranium;  and  to  these  last  we  espe- 
cially wish  to  limit  the  term  functional,  although  it  might  very  well 
include  all  those  conditions  which,  so  far  as  our  knowledge  extends, 
are  unconnected  with  actual  disease  of  nerve-structure. 

They  divide  themselves  naturally  into  three  main  groups;  (a) 
those  connected  with  disturbances  of  the  circulation,  whether  in 
excess  or  deficiency;  (b)  those  connected  with  disorder  in  the  pro- 
cess of  digestion  and  assimilation;  and  (c)  those  which  are  more 
properly  called  nervous.  Of  the  two  former  it  is  to  be  remarked, 
that  while  coincident,  and  bearing  some  relation  to  each  other  as 
cause  and  effect,  the  functional  disturbance  of  the  brain  is  not  to 
be  regarded  simply  as  a  symptom  of  disorder  of  the  circulation,  or 
of  the  digestion;  for  it  is  not  a  necessary  or  a  constant  effect.  The 
same  amount  of  disorder  is  not  uniformly  followed  by  similar  dis- 
turbance in  any  two  individuals,  or  in  the  same  individual  at  dif- 
ferent times;  while  the  identical  symptoms  may  be  noticed  in  the 
same  person  under  very  different  states.  Hence,  the  term  nervous 
might  be  justly  applied  to  all;  but  it  is  important  to  bear  in  mind 
that  the  connexion  exists,  and  that  the  disorder  of  the  circulation 
or  of  the  stomach  being  removed,  the  functional  disturbance  of  the 
brain  for  the  time  ceases. 

Insanity  might,  with  some  show  of  reason,  be  included  in  this 
section,  as  its  relation  to  disease  of  the  brain  is  so  entirely  unknown. 
We  have  already  endeavoured  to  point  out,  in  speaking  of  delirium, 
the  means  of  its  diagnosis,  to  which  it  is  unnecessary  again  to  allude. 

The  symptoms  of  functional  disturbance  cannot  be  classified 
according  to  the  disorders  of  other  organs  with  w'hich  they  are  asso- 
ciated; we  shall,  therefore,  take  them  in  the  same  order  adopted  in 
the  previous  chapter,  considering  them  in  their  relations  to  intel- 
lectual faculties,  to  sensations,  and  to  power  of  motion. 


FUNCTIONAL    DISTURBANCE.  165 

Here  we  meet  with  neither  coma  nor  delirium ;  their  counter- 
parts, however,  maybe  traced;  for  we  have  the  semi-stupor  seen 
in  what  is  called  the  hydrencephaloid  disease  of  childhood,  the 
mock  hydrocephalus  following  on  exhaustion,  either  from  diarrhoea, 
from  excessive  depletion,  or  from  want  of  nourishment.  In  care- 
fully following  up  the  rational  principles  of  diagnosis,  which  it  is 
the  object  of  these  pages  to  elucidate,  the  error  which  this  very 
name  implies  will  be  easily  avoided,  because  on  the  one  hand  the 
history  will  teach  us  that  the  child  has  been  exposed  to  depressing 
causes,  while  on  the  other  its  actual  condition  will  be  defective  in 
some  of  those  characters  which  are  necessarily  associated  with  in- 
flammation of  the  brain;  as  we  find,  for  example,  a  cool  scalp  or  a 
depressed  fontanelle:  when  mistakes  have  been  made  they  have 
arisen  from  limited  inquiry,  and  from  reasoning  upon  partial  infor- 
mation. Another  counterpart  to  the  condition  of  coma  in  severe 
disease,  is  seen  in  the  fainting-fit  in  the  adult,  which  is  sometimes 
simulated  by  hysteria,  but  is,  in  truth,  merely  an  expression  of  want 
of  blood  in  the  brain.  Then  again,  corresponding  to  hallucinations 
and  illusions,  we  find  ocular  spectra  and  deceptive  noises,  as  well 
as  all  the  morbid  fancies  of  the  hysterical  and  hypochondriac. 
More  common  forms  of  disturbance  are  met  with  in  the  complaint 
of  loss  of  power  to  carry  out  an  ordinary  train  of  thought,  or  tran- 
sient loss  of  memory. 

Among  sensations  may  be  reckoned  as  the  most  common,  head- 
ache and  giddiness;  then  partial  blindness,  tingling,  ringing  in  the 
ears;  to  these,  again,  must  be  added  the  exaggeration  of  pain 
which  is  produced  by  constantly  thinking  of  and  directing4the 
attention  to  it. 

Muscular  spasm  and  paralysis  are  not  often  seen  as  a  consequence 
of  functional  disturbance,  for,  although  we  do  not  know  that  chorea 
is  associated  with  any  organic  change  in  the  condition  of  the  brain 
and  nerves,  it  has  too  much  the  characters  of  a  distinct  and  definite 
disease  to  be  classed  along  with  those  we  are  at  present  considering: 
both  choreic  movements  and  paralysis  are  simulated  in  hysteria. 
Convulsions,  on  the  other  hand,  occur  in  infancy  quite  as  often  in 
consequence  of  functional  disturbance  as  of  organic  disease:  among 
adults  we  can  scarcely  include  in  this  class  those  which  are  seen  in 
cases  of  blood-poisoning, — uraemia,  and  puerperal  convulsions, — 
although  they  be  not  directly  connected  with  organic  change  in  the 
brain. 

In  the  investigation  of  "head-symptoms"  generally,  the  same 
rules  must  be  followed  as  in  the  more  severe  diseases  of  the  brain. 
We  have  to  make  out  the  history  of  the  case,  and  the  order  of 
sequence  of  the  various  phenomena,  remembering  that,  as  the 
attention  of  the  patient  is  fixed  on  what  he  considers  the  most 
important  symptom,  he  generally  dates  thercommencement  of  his 
illness  from  the  period  of  its  first  appearance,  and  it  is  only  by 
close  inquiry  that  he  can  be  got  to  admit  any  previous  derangement 


166  DISEASES    OF   THE    BR  A IX. 

of  health:  indeed,  it  may  have  been  so  insidious  as  to  escape  his 
observation.  Then  diligent  search  must  be  made  for  other  indica- 
tions referring  to  the  brain  or  nerves,  besides  that  of  which  the 

patient  complains,  lest,  perchance,  it  should  be  discovered  that  it  is 
but  one  link  in  a  chain  of  symptoms  which  proves  the  existence  of 
some  severe  disease  of  the  enccphalon. 

In  the  order  of  examination  we  shall  next  be  able  to  exclude 
febrile  and  inflammatory  states;  and  then  the  appearance  of  the 
patient  in  regard  to  conditions  of  anrcmia  or  plethora  naturally 
occupies  our  attention:  not  indeed  in  the  more  marked  forms  of 
blood  changes,  where  hemorrhage,  purpura,  or  chlorosis  constitute 
distinct  classes  of  disease,  but  in  such  minor  deviations  from  health 
as  perhaps  are  only  testified  by  the  circumstance  that  the  symptoms 
are  either  relieved  or  aggravated  by  the  recumbent  posture.  Along 
with  this  we  naturally  take  the  condition  of  the  organs  of  circula- 
tion, when  a  slight  cardiac  murmur,  unaccompanied  by  other  evi- 
dence of  disease,  may  be  enough  to  explain  uneasy  sensations  in 
the  head,  which  are  far  more  tormenting  to  the  patient  than  the 
dyspnoea  or  palpitation  which  we  might  expect  to  find,  and  the  very 
existence  of  which  he  utterly  ignores. 

The  lungs,  too,  must  be  carefully  examined,  but  this  rather  for 
their  negative  than  their  positive  results;  for  we  are  not  now  deal- 
ing with  symptoms  relating  to  severe  disease,  but  with  the  little 
torments  which  invalids" frequently  suffer;  and,  for  their  successful 
treatment,  we  are  rather  indebted  to  experience  than  to  pathology. 

A  step  further  brings  us  to  the  organs  of  digestion,  which  are 
moup  often  the  apparent  exciting  cause  of  functional  disturbance 
»than  any  other.  But  it  is  in  their  minor  derangements  only,  that 
we  can  be  justified  in  regarding  the  cerebral  symptoms  as  functional. 
A  bilious  headache  is  a  thing  of  every-day  occurrence;  but  we  must 
carefully  analyze  what  -is  meant  when  a  person  says  he  is  bilious: 
we  may  employ  such  a  phrase  as  a  compendious  expression  of  a 
certain  state,  but  we  must  be  careful  how  we  listen  to  it  from  the 
mouth  of  a  patient.  Frequent  vomiting,  obstinate  constipation,  or 
severe  diarrhoea  must  make  us  look  further  into  the  case;  slight 
nausea, loss  of  appetite,  discomfort  during  digestion,  and  irregularity 
in  the  action  of  the  bowels  may  justify  the  conclusion  that  the 
uneasy  sensations  in  the  head  are  only  functional.  In  addition  to 
this,  it  will  be  found  in  practice  that  a  patient  seldom  applies  for 
relief  at  their  first  occurrence,  when  connected  with  derangement 
of  the  digestive  organs.  Dyspeptic  symptoms  arise  by  such  slow 
degrees  that  few  have  reached  the  middle  period  of  life  without 
suffering  from  them;  and  it  is  only  when  they  are  more  than  ordi- 
narily severe  that  advice  is  sought:  to  some  people  they  become  the 
ordinary  state  of  health,  and  immunity  from  them  the  exception; 
they  have  had  their  headaches  over  and  over  again,  and  begin  to 
look  upon  them  as  necessary  evils,  till  some  strange  sensation 
arouses  suspicion  of  unknown  mischief.  The  frequent  recurrence 
of  such  head-symptoms, — their  habitual  association  with  attacks  of 


FUNCTIONAL    DISTURBANCE.  167 

more  severe  indigestion  or  more  than  usual  irregularity  in  the 
bowels, — their  transitory  character,  and  the  circumstance  that 
excitement  and  motion  succeed  in  dispelling  them  after  a  little 
starvation,  or  a  little  purgation, — all  this  affords  valuable  assistance 
in  discriminating  these  transient  disturbances  from  the  more  severe 
forms  of  cerebral  disease. 

The  state  of  the  urine,  after  all  that  has  been  said  of  the  con- 
nexion of  diseases  of  the  brain  with  those  of  the  kidney,  will  not 
fail  to  be  investigated. 

The  state  of  the  sexual  organs  is  chiefly  related  to  that  form  of 
disorder  which  we  have  denominated  the  nervous.  We  have  seen 
something  of  this  mysterious  connexion  in  hysteria, — a  condition 
which  tends  greatly  to  heighten  and  augment  the  symptoms  derived 
from  this  source,  though  they  may  have  their  existence  quite  inde- 
pendent of  it;  but  all  the  disorders  of  these  organs,  and  especially 
their  undue  excitement,  must  be  borne  in  mind  in  relation  to 
"nervous"  disorders.  Painful  as  the  inquiry  must  be  to  every 
right-feeling  man,  we  must  not  neglect  the  suggestions  of  the  wan 
aspect  and  the  shrinking  eye  of  a  young  man  in  a  state  of  nervous- 
ness bordering  on  insanity,  who  has  brought  upon  himself,  as  the 
fruit  of  his  vices,  the  penalty  of  a  constant  spermatorrhoea;  duty 
commands  us  to  endeavour  to  save  him  from  himself,  no  less  than 
from  the  clutches  of  the  disgusting  charlatan  who  only  keeps  up  while 
he  preys  upon  the  disorder.  But  we  tread  upon  delicate  ground, 
and  I  must  earnestly  warn  my  younger  readers  against  the  scarcely 
less  obnoxious  and  obscene  familiarities  of  the  legitimate  specialist. 

This  class  of  cases  borders  much  more  closely  on  the  organic 
diseases  which  have  been  already  discussed  than  either  of  the  pre- 
ceding ;  sometimes  it  is  hard  to  be  discriminated  from  mental 
alienation.  The  over-worked  brain  of  the  professional  man  who  is 
labouring  after  eminence  or  wealth,  and,  still  more,  the  over-excited 
brain  of  the  stock-jobber  or  speculator,  after  a  time  becomes  ex- 
hausted and  unfit  for  the  longer  performance  of  duties  beyond  its 
strength;  and  apoplexy,  paralysis,  meningitis,  or  dementia  put  a 
sudden  stop  to  his  foolish  schemes.  It  is  vain  to  attempt  any  more 
correct  classification  of  these  symptoms;  but,  with  reference  to 
diagnosis,  it  is  well  to  remember  that  they  may  be  but  the  precur- 
sors of  more  serious  mischief.  On  the  other  hand,  it  is  always  a 
state  of  depressed  vitality  which  gives  prominence  to  symptoms 
generally  called  "nervous."  Over-anxiety  and  care,  whether  ac- 
companied by  straitened  circumstances,  which  deprive  the  individual 
of  many  of  the  comforts,  perhaps  of  the  necessaries  of  life, — or 
leading  to  irregular  hours,  when  the  system  is  alternately  exhausted 
by  long  fasting,  and  taxed  by  subsequent  repletion, — not  less  than 
a  life  marked  by  habits  of  gayety,  dissipation,  and  excess,  must  in 
course  of  time  undermine  the  strongest  constitutions,  and  expose 
them  to  these  attacks.  By  repairing  the  waste,  giving  tone  to  the 
system  and  relaxation  to  the  brain,  we  can  best  hope  to  relieve 
present  symptoms,  and  ward  off  more  serious  mischief. 


1G8 


CHAPTER  XIV. 

DISEASES    OF   THE   SPINAL   CORD. 

I  nil  a  mm  at  ion  rare  as  an  Idiopathic  Disease — Its  History  and 
Symptoms — Connexion  with  Caries — Spinal  Irritation — Chronic 
Disease. 

Inflammation  of  the  spinal  cord,  except  as  a  consequence  of 
accident  or  injury,  is  confessedly  so  rare,  that  it  demands  but 
little  notice  in  a  work,  the  avowed  object  of  which  is  to  conduct  the 
student  to  right  principles  of  diagnosis.  In  its  general  character 
it  ranks  among  acute  diseases,  and  it  is  often  accompanied  by 
symptoms  of  cerebral  inflammation:  these  may  arise  either  from 
the  sictual  spread  of  the  inflammatory  action  to  the  membranes  of 
the  brain,  or  they  may  be  produced  merely  by  the  sympathy  neces- 
sarily existing  between  parts  whose  functions  are  so  closely  con- 
nected: such  symptoms  have  been  found,  both  with  and  without 
sensible  change  within  the  cranium. 

The  history  of  the  case  perhaps  reveals  the  previous  occurrence 
of  some  accident  or  strain,  or  casual  exposure  to  cold,  which  may 
be  reckoned  among  its  more  usual  causes.  In  every  instance  it 
gives  an  account  of  a  sudden  seizure  as  the  starting-point  from 
Avhich  to  date  the  sequence  of  the  phenomena,  while  the  greater 
or  less  rapidity  with  which  they  succeed  each  other,  enables  us  to 
judge  of  the  relative  severity  of  the  attack. 

The  early  stages  of  the  disease  are  liable  to  be  confounded  with 
rheumatism  and  neuralgia;  but  on  closer  investigation  it  will  be 
found  that  there  is  more  of  general  disturbance  than  the  local  and 
limited  nature  of  the  attack  would  warrant  us  in  expecting,  were 
the  pain  due  to  either  of  these  diseases.  It  is  always  characterized 
by  pain  somewhere  in  the  region  of  the  spine,  and  generally  pretty 
high  up;  of  a  fixed  character,  and  notably  increased  by  any  quick 
change  of  posture.  In  well-marked  cases  this  pain  is  accompanied 
by  spasm,  having  somewhat  of  a  tetanic  character,  especially  in  the 
muscles  of  the  neck  and  upper  part  of  the  back;  paralysis  some- 
times comes  on  early.  These  are  exactly  the  signs  which,  a  priori, 
we  should  expect  to  meet  with  in  inflammation  of  the  cord,  as  they 
are  due  either  to  the  irritation  or  the  subsequent  disorganization  of 
the  large  bundles  of  nerve  fibres.  In  many  cases  we  are  perplexed 
by  the  paucity  and  comparatively  slight  character  of  the  symptoms 
directly  traceable  to  the  spine,  and  their  very  constant  association, 
when  they  have  attained  a  certain  degree  of  severity,  with  others 
which  are  more  distinctly  cerebral.  Paralysis,  or  loss  of  sensation, 
indicates  a  further  advance:   the  inflammation  is  no  longer  limited 


DISEASES  OF  THE  SPINAL  CORD.         169 

to  the  membranes,  but,  as  in  the  chronic  forms  of  the  disease,  some 
change  has  actually  passed  upon  the  nerve  fibre. 

The  condition  of  the  bones  should  next  occupy  our  attention,  in 
so  far  as  their  regularity  of  position?  capability  of  movement,  and 
tenderness  on  pressure  are  concerned;  and  it  may  be  laid  down  as 
a  rule  in  diagnosis,  that  "when  the  cord  is  inflamed,  and  especially 
■when  spinal  meningitis  is  present,  any  sudden  twist  or  jarring 
movement  gives  more  evidence  of  pain  than  mere  pressure.  Per- 
manent displacement,  as  a  result  of  caries,  may  have  proceeded  to 
a  very  great  degree  without  any  distinct  evidence  of  its  impeding 
nervous  action;  and  when  paralysis  at  length  occurs,  it  is  often 
due  to  inflammatory  action  set  up  by  the  contiguity  of  diseased 
structure.  Probably  this  cause  operates  even  more  frequently  than 
the  pressure  dependent  on  increasing  distortion:  in  such  circum- 
stances the  characters  of  an  acute  attack  are  generally  wanting. 

As  connected  with  this  subject  a  few  words  must  be  said  upon  tbe  somewhat 
fashionable  ailment  denominated  spinal  irritation.  It  is  a  great  misfortune  when 
a  name  is  given  to  any  affection  which  conveys  an  erroneous  impression  of  its  na- 
ture: irritation  of  a  nerve  produces  either  momentary  spasm  or  transient  sensa- 
tion, as  the  course  of  the  nervous  influence  is  centrifugal  or  centripetal:  and  a 
continuance  or  repetition  of  the  irritation  will  produce  the  same  phenomena  in  a 
more  or  less  continued  succession:  in  this  view  all  pain  and  all  sp^sm  may  be 
classed  generally  under  nervous  irritation,  and  so  the  true  spinal  irritation  which 
characterizes  the  first  stage  of  inflammation  of  the  cord  produces  fixed  local  pain, 
and  distinct  local  spasm.  On  the  other  hand,  excessive  tenderness  or  sensibility 
— hyperesthesia,  as  it  is  called, — such  as  occurs  in  inflamed  states  of  organs, 
whether  with  or  without  actual  pain,  as  well  as  the  excessive  mobility  seen  in 
chorea  or  delirium  tremens,  may  be  said  to  be  due  to  irritability,  but  are  certainly 
not  the  effect  of  irritation.  Again,  loss  of  sensation  and  loss  of  motion  are  not 
evidence  of  either  irritability  or  irritation,  but  of  interruption  to  the  transmission 
of  nervous  influence,  or  loss  of  power  in  the  brain  to  take  cognizance  of  the  one 
or  originate  the  other. 

In  what  is  called  spinal  irritation  all  these  phenomena  may  be  met  with,  and 
are  mixed  up  together  in  the  most  incongruous  manner.  Some  inquirers  have 
deceived  themselves  into  the  belief  tha*t  the  symptoms  were  capable  of  classifica- 
tion, and  have  even  detailed  examples  of  cases  in  which  there  was  some  pretension 
to  scientific  order  and  natural  sequence;  but  in  these  instances  they  have,  no  doubt, 
been  misled  by  their  having  put  leading  questions  to  persons  in  whom  the  promi- 
nent condition  was  a  disordered  fancy,  and  by  their  having  readily  obtained  an- 
swers in  the  affirmative.  Take  the  patient's  own  account  of  symptoms,  or  put  the 
leading  questions  in  such  a  form  as  to  develop  their  incongruity,  and  no  doubt 
need  remain  of  the  truth  of  what  is  here  stated.  There  is  often  complaint  of  pain 
in  the  back,  but  its  character,  in  place  of  being  fixed,  and  local,  and  deep-seated, 
is  diffused,  superficial,  and  variable.  Movement,  at  one  time  alleged  to  be  impos- 
sible, is  effected  with  perfect  ease  at  another,  when  the  attention  is  turned  to  some- 
thing else:  the  slightest  touch,  when  the  question  is  put,  will  be  said  to  give  pain, 
and  yet  firm  pressure  or  a  considerable  jar  at  another  moment  is  unheeded.  This 
character  alone  is  sufficient  to  distinguish  such  complaints  of  pain  from  those  that 
are  of  real  importance;  the  same  remarks  apply  to  the  spasms  and  the  paralysis 
which,  each  in  turn,  may  form  the  principal  feature  of  the  disorder:  they  may,  by 
a  little  dexterity  on  the  part  of  the  observer,  be  proved  to  have  their  existence 
only  in  the  exuberant  fancy  of  the  patient.  If  the  distinctions  in  the  use  of  terms 
just  pointed  out  had  been  clearly  kept  in  view,  we  should  probably  never  have 
had  any  doubts  or  confusion  on  this  subject. 

Chronic  disease  of  the  cord  is  a  subject  on  which  little  can  be 


170  DISEASES    OF    THE    SPINAL    CORD. 

said  in  a  diagnostic  point  of  view.  The  great  evidence  of  its 
existence  is  to  be  derived  from  the  paralysis  which,  sooner  or  later, 
always  accompanies  it;  but  this  symptom  alone  can  give  little 
information  regarding  the  effuses  of  its  occurrence;  because,  as 
will  be  shown  in  the  sequel  (see  Chap.  XV.  §  2,)  one  which  really 
acts  only  on  a  small  fragment  of  the  medulla,  produces  symptoms 
such  as  we  should  imagine  indicative  of  disease  of  a  much  more 
extensive  form. 

The  chief  guide  in  determining  the  nature  of  the  lesion  is  the 
order  of  sequence  among  the  phenomena;  thus,  in  a  very  general 
way,  it  may  be  stated  that  pressure  on  the  cord  gives  rise  to  feel- 
ings of  formication,  tingling,  heat  and  cold,  &c,  simultaneously 
with  pain  in  the  back ;  whereas  in  inflammatory  action,  even  of  a 
chronic  kind,  the  pain  is  more  usually  associated  in  the  first  in- 
stance with  spasm,  and  the  sensation  of  numbness  comes  on»  at  a 
later  period.  Both  of  these  are  again  distinguished  from  the 
common  cases  of  paraplegia  dependent  on  atrophy  of  the  cord  by 
the  absence  of  pain  in  the  latter  condition  altogether.  Another 
circumstance  which  may  serve  for  our  guidance  in  this,  as  it  does 
in  other  organs,  is  the  knowledge  which  pathology  gives  of  the 
relative  position  and  extent  of  diseased  action;  atrophy  is  confined 
to  the  lower  end  of  the  cord;  inflammation  is  apt  to  diffuse  itself 
widely;  tumours  are  most  commonly  found  towards  its  upper 
extremity;  and  each  of  these  positions  must  of  necessity  be  cha- 
racterized by  phenomena  of  different  kinds. 

I  have  said  nothing  of  the  means  of  distinguishing  spinal  arach- 
nitis from  inflammation  of  the  substance  of  the  cord,  nor,  again,  of 
the  difference  in  symptoms  between  inflammatory  softening  and 
hardening;  they  are  far  too  uncertain  to  be  laid  down  for  the 
guidance  of  the  student,  who  may  rest  quite  satisfied  if  he  can  dis- 
tinguish inflammation  either  of  acute  or  chronic  form  from  other 
lesions. 


171 


CHAPTER  XV. 

PARALYSIS. 

Loss  of  Sensation — of  Power  of  Motion — Incomplete  Paralysis. 

— §  1,  Hemiplegia — Its  Mode  of  Incursion — Its  Central  Origin 

—  Causes  and  Complications — §  2,  Paraplegia — Its  Causes  and 

Varieties — Cfeneral  Paralysis — Paralysis  Agitans — §  3,  Local 

Paralysis — Its  Mean ing — Nervous — Muscular. 

By  paralysis  is  meant  the  inability  to  transmit  nervous  influence, 
whether  in  a  central  or  in  a  peripheral  direction ;  but  the  term  is 
more  usually  applied  to  that  manifestation  of  it  which  consists  in 
loss  of  muscular  power:  loss  of  sensation  has  been  called  ansestliesia, 
and  a  corresponding  term  for  muscular  paralysis  has  recently  been 
invented — acinesis :  loss  of  power  of  motion  without  diminished 
sensibility  is  much  more  frequently  met  with  than  the  converse,  and 
when  the  two  are  coincident  the  diminution  of  mobility  is  generally 
much  greater  than  that  of  sensibility.  Taking  into  consideration 
the  compound  nature  of  most  of  the  nervous  tracts,  it  will  rather 
appear  surprising  that  the  two  conditions  should  ever  be  apart, 
than  that  they  should  frequently  be  found  associated  in  the  same 
individual;  and  in  those  exceptional  cases  in  which  the  nerve  fibres 
are  wholly  sensory,  or  wholly  motor,  we  find  that  the  very  same 
circumstances  which  in  the  one  lead  to  anaesthesia;  in  the  other 
produce  muscular  palsy.  In  prosecuting  the  diagnosis  of  nervous 
diseases  there  would  therefore  seem  to  be  no  advantage  in  separating 
them  in  a  pathological  view;  and  in  semeiology,  as  has  been  already 
observed,  objective  phenomena  are  generally  more  certain  and  con- 
clusive than  subjective. 

The  history  of  the  incursion  of  paralysis  and  the  symptoms  which 
have  preceded  its  development,  give  us  the  first  clue  to  discover  the 
cause  on  which  it  depends ;  but  it  is  also  of  use  in  enabling  us  to 
determine  whether  the  complaint  made  by  the  patient  of  loss  of 
power  or  numbness  be  based  on  a  real  alteration  of  the  condition 
of  the  parts,  or  be  entirely,  or  partly  imaginary;  a  point  which  is 
often  very  difficult  to  decide  when  the  paralysis  of  the  nerve  is  not 
complete.  In  real  paralysis  we  shall  either  find  that  at  one  time  it 
has  been  more  perfect  than  it  now  is,  and  that  it  commenced  with 
a  comparatively  sudden  seizure,  or  that  it  has  come  on  gradually 
and  has  been  slowly  increasing:  its  amount,  too,  is  the  same  at 
different  times  of  observation. 

This  may  be  best  measured  by  power  of  resistance ;  but  it  is 
necessary  to  bear  in  mind  that  spasm  is  sometimes  associated  with 
paralysis,  and,  while  there  is  little  or  no  voluntary  power,  the 


172  PARALYSIS. 

muscle  under  the  influence  of  spasm  may  offer  great  resistance  to 
movement  of  the  limb  by  another:  such  an  occurrence  can  only 
mislead  when  the  observation  is  very  superficial;  one  set  of  muscles 
only  is  affected  by  the  spasm,  and  that  for  but  a  short  period,  the 
limb  under  all  other  circumstances  remaining  in  a  powerless  condi- 
tion :  such  spasm  is  only  seen  when  the  paralysis  is  complete:  it  is 
referrible  to  some  sort  of  reflex  action. 

The  duration  of  the  affection  aids  in  determining  the  nature  of  the  lesion;  we 
discriminate  cases  according  as  we  can  trace  an  invasion  of  recent  disease  on  old 
standing  paralysis,  or  the  latter  supervening  on  illness  of  longer  duration,  or  all 
the  symptoms  commencing  together.  Similarly  its  mode  of  incursion  may  throw 
light  on  its  cause,  as  we  find  it  occurring  suddenly  in  apoplexy,  or  more  slowlv  in 
chronic  disease;  ushered  in  by  a  fit  or  loss  of  consciousness,  or  gradually  spreading 
from  muscle  to  muscle;  attaining  its  maximum  in  a  few  hours,  or  advancing  from 
week  to  week.  Occasionally  a  fallacy  presents  itself  in  the  circumstance  that  some 
slight  paralysis  of  long  standing  is  only  first  observed  when  febrile  disturbance  is 
present;  such,  for  instance,  as  slight  strabismus,  of  which  the  patient  was  quite 
unconscious.  This  is  best  corrected  by  ascertaining  whether  there  be  any  recent 
change  in  function ;  double  vision  necessarily  attends  recent  strabismus,  unless 
the  sight  of  one  eye  be  lost. 

In  all  forms  of  incomplete  paralysis,  whether  the  patient  complain  of  inability 
to  walk,  of  imperfect  power  of  the  hand  and  arm,  or  of  mere  feelings  of  numbness, 
while  yet  there  is  no  muscle  which  cannot  be  brought  to  act  when  he  is  at  rest 
and  no  resistance  offered,  we  are  beset  with  difficulties,  because,  on  the  one  hand, 
the  cause  of  the  disease  is  exceedingly  obscure,  and  on  the  other,  its  main  features 
are  often  simulated  by  hysteria  or  hypochondriasis.  It  is  not  only  during  life 
that  this  obscurity  prevails,  but  even  after  death  it  may  be  wholly  impossible  to 
point  out  the  lesion  on  which  it  depended.  Were  other  instances  wanting,  very 
forcible  evidence  of  this  fact  is  derived  from  instances  of  what  is  called  the  para- 
lysis of  the  insane. 

In  such  cases  we  have  to  seek  for  other  evidence  of  disease  of  the  brain  or  nerves, 
if  any  such  can  be  traced,  in  actions  which  do  not  come  under  the  power  of  voli- 
tion; to  study  the  character  of  the  patient,  as  it  may  evince  nervousness,  hvsteria, 
exalted  imagination,  unnatural  excitement  or  depression,  and  to  compare  one  day 
with  another  the  increase  or  diminution  of  symptoms.  In  hysteria  especially,  va- 
riation is  the  ordinary  rule;  consistency,  the  exception.  A  patient  will  fail  toshow 
any  power  of  resistance,  or  will  bear  pretty  severe  pinching  at  one  observation, 
and  at  the  next  the  symptoms  have  undergone  a  complete  change.  But  it  is  to  be 
remembered  that  the  different  result  may  be  due  to  the  manner  in  which  the  in- 
vestigation has  been  made.  It  has  happened  in  my  own  experience,  that  one  phy- 
sician pronounced  anaesthesia  to  be  complete,  while  another  obtained  distinct  evi- 
dence of  sensation  ;  because,  by  the  one,  only  a  transient  impression  was  made, 
which  was  not  transmitted  to  the  sensorium,  while  the  other  maintained  the  irri- 
tation for  some  time,  and  at  length  consciousness  of  pain  became  apparent. 

Where  we  have  reason  to  suspect  simulation  or  imaginary  ailment,  various  de- 
vices must  be  had  recourse  to  in  abstracting  the  attention,  in  avoiding  leading 
questions,  or  perhaps  putting  them  in  a  wrong  direction,  so  as  to  bring  out  a  want 
of  harmony  and  consistency  in  the  tale;  we  must  watch  the  action  of  those  mus- 
cles which  are  less  under  the  control  of  the  will,  employed  in  winking,  in  speech, 
and  in  deglutition;  but,  besides  this,  we  may  learn  much  from  the  gait  and  move- 
ments of  the  patient,  as  the  real  paralytic  makes  vain  efforts,  which  end  in  partial 
or  complete  failure;  the  " malade  imagiiutire'''  evidently  does  not  attempt  to  bring 
the  muscles  into  play  at  all ;  the  will  is  paralyzed,  and  not  the  instruments  which 
it  employs.  The  test  of  resistance,  which,  when  judiciously  applied,  generally 
serves  to  detect  any  exaggeration  or  imposture,  is  also  of  great  value  in  discrimi- 
nating cases  in  which  the  practitioner  is  liable  to  be  misled  by  a  phrase  employed 
by  the  patient  that  he  has  "lost  the  use  of"  a  limb,  when  it  is  only  motionless 
from  stiffness  or  pain  of  the  joint;  just  as,  on  the  other  hand,  it  may  detect  the  ex- 
istence of  paralysis  when  the  patient  speaks  of  it  as  rheumatism. 


HEMIPLEGIA.  173 

"We  have  no  such  test  to  apply  in  regard  to  the  degree  of  sensibility,  which  must 
rest  wholly  on  the  report  of  the  individual;  but  it  is  well  to  remember  that  it  sel- 
dom exists  without  loss  of  power  at  the  same  time.  Loss  of  sensation,  when  stand- 
ing alone,  except  in  the  case  of  one  or  two  special  nerves,  is  most  probably  exag- 
gerated; but  as  a  sense  of  numbness  or  partial  insensibility,  it  may  be  the  first  in- 
dication of  coming  paralysis  which  excites  the  patient's  notice. 

The  next  point  is  to  determine  the  form  and  distribution  of  the 
affection,  because  a  knowledge  of  the  number  of  muscles  para- 
lyzed, and  their  relations  to  the  nervous  system,  is  the  principal 
element  in  forming  a  correct  hypothesis  regarding  the  seat  and 
nature  of  the  cause.  The  value  of  paralysis,  as  a  symptom  of  dis- 
ease, depends  entirely  on  our  acquaintance  with  the  origin  and 
course  of  the  nerves,  and  on  our  being  able  to  determine  the  point 
at  which  the  interruption  to  volition  occurs,  whether  by  failure  of 
the  brain  as  the  organ  of  mind  to  receive  the  power  of  the  will,  or 
of  the  nerve-tubes  to  transmit  that  will;  and  whether  the  interrup- 
tion, when  affecting  its  transmission  only,  can  be  referred  to  the 
tract  of  a  single  nerve,  or  must  be  traced  hack  to  the  common  exit 
or  origin  of  several.  We  recognise  in  practice  three  main  divisions 
of  paralysis, — hemiplegia,  affecting  one  side  of  the  body;  paraple- 
gia, implicating  both  sides  equally,  or  nearly  to  the  same  degree, 
up  to  a  certain  height;  and  local  paralysis,  which  maybe  either 
limited  to  a  group  of  muscles  supplied  by  one  nerve,  or  one  set  of 
nerves,  or  to  single  muscles  by  themselves, — in  the  former  the  dis- 
ease is  probably  seated  in  the  course  of  the  nervous  trunk;  in  the 
other,  in  the  muscular  structure. 


•? 


§  1.  Hemiplegia. — This  form  of  paralysis  is  distinguished  by  its 
limitation  to  the  muscles  on  one  side  of  the  body:  a  line  corre- 
sponding to  the  axis  of  the  spinal  column  separates  those  which  can 
no  longer  be  called  into  exercise  by  volition,  from  those  which  re- 
tain their  healthy  action.  In  its  most  extended  sense  the  one-half 
of  the  tongue,  the  face,  the  chest,  and  the  abdomen,  as  well  as  the 
arm  and  leg  of  the  affected  side,  are  all  implicated;  but  such  a 
condition  rarely  exists.  Some  of  the  muscles  are  more  easily 
affected,  some  more  quickly  regain  the  power  of  motion;  and  we 
seldom  see  a  case  in  which  hemiplegia  is  complete.  It  may,  there- 
fore, become  a  question,  when  certain  muscles  of  one  side  of  the- 
body  are  paralyzed,  whether  the  case  should  be  considered  as  one 
of  partial  hemiplegia  or  of  local  paralysis.  And  this  is  not  a  mere 
question  of  names;  the  correctness  of  the  term  employed  implies  a 
correct  judgment  regarding  the  causes  of  the  phenomena  observed; 
because,  if  we  regard  it  as  hemiplegia,  we  attribute  the  palsy  to  a 
cause  acting  upon  the  nervous  centres,  and  thus  affecting  the  nerves 
derived  from  them  on  one  side ;  whereas  local  paralysis  points  to  a 
cause  affecting  only  the  nerve  itself,  and  having  no  necessary  con- 
nexion with  the  central  structures  at  all;  ultimately  it  may  impli- 
cate them,  primarily  it  is  independent.  The  answer  to  the  question 
is,  in  fact,  the  diagnosis  of  the  case. 


174  PARALYSIS. 

The  history  divides  cases  of  hemiplegia  very  naturally  into  those 
ushered  in  by  a  "fit,"  and  those  in  which  there  has  been  no  loss  of 

M-ionsness.     In  the  former  class  there   is  no   doubt   whatever 
it  the  character  of  the  paralysis:  its  cause  is  manifestly  central; 

I  so  far  as  observations  have  hitherto  gone,  its  extent  throws  no 
light  whatever  upon  the  particular  portion  of  the  brain  involved. 
Sometimes  the  progress  of  the  case  and  the  duration  of  the  para- 
lysis are  of  some  assistance  in  determining  the  nature  of  the  changes 
which  in  the  first  instance  caused  the  fit. 

In  the  latter  class  the  symptoms  may  have  come  on  gradually 
or  suddenly ;  depending,  in  the  one  case,  on  disorganization  of  the 
brain,  softening,  or  abscess;  in  the  other,  on  extravasation  of 
blood.  I  am  not  aware  that,  in  any  case,  serous  effusion  has  pro- 
duced paralysis  without  preceding  evidence  of  inflammation,  or  the 
occurrence  of  a  fit  either  distinctly  convulsive  in  character,  or  more 
nearly  resembling  apoplexy.  When  slowly  developed,  we  seek  for 
evidence  of  previous  disease  of  the  brain  in  headache,  earache,  dim- 
ness of  sight  in  one  eye,  double  vision,  ptosis,  deafness,  or  impair- 
ment of  intellectual  power,  loss  of  memory,  &c.^  Occasionally, 
while  such  changes  point  to  some  form  of  chronic  disease  of  the 
brain,  the  paralysis  itself  comes  on  rapidly;  in  other  instances  it 
is  the  only  symptom,  and  beginning  with  partial  failure  of  the  power 
of  volition  over  certain  muscles,  it  gradually  increases  both  in  ex- 
tent and  in  intensity.  When  dependent  on  extravasation  of  blood, 
the  patient  has  enjoyed  his  usual  state  of  health  up  to  the  period  of 
seizure;  suddenly  he  becomes  conscious  of  numbness,  or  loss  of 
power  in  one  of  his  limbs,  and  the  paralysis  soon  involves  the 
greater  part  of  that  side  of  the  body.  Occasionally  the  occurrence 
of  headache  leads  to  a  strong  presumption  in  favour  of  extravasa- 
tion ;  but  this,  probably,  is  not  the  rule  in  such  cases. 

The  diagnosis  between  hemiplegia  and  local  paralysis, — between 
loss  of  power  depending  on  changes  occurring  within  the  cranium, 
and  those  affecting  the  nerve  or  the  muscle — in  all  cases  in  which 
the  history  fails  to  point  out  symptoms  directly  connected  with  the 
cncephalon,  must  rest  entirely  upon  the  distribution  of  the  affection 
in  its  relation  to  the  anatomy  of  the  nervous  system.  If  we  find 
'that  the  palsy  includes  muscles  supplied  by  nerves  which  have 
different  origins,  and  have  no  direct  communication  with  each  other 
at  their  exit,  we  may  be  certain  that  the  disorder  is  central. 

Hemiplegia  is  very  rarely  indeed  associated  with  disease  of  the  spinal  cord:  the 
space  in  the  canal  is  so  limited,  that  pressure  on  one  half  is  sure  to  affect  the  other, 
although,  perhaps,  in  slighter  degree;  and  the  two  halves  are  so  intimately  united, 
that  inflammation  of  the  one  never  fails  also  to  attack  the  other:  paralysis  of  one 
side  of  the  body  is  therefore  always  found  with  a  minor  degree  of  the  same  affec- 
tion on  the  other,  when  the  disease  is  situated  in  the  cord,  and  the  case  must  be 
considered  as  one  of  paraplegia. 

In  some  cases,  hemiplegia  may  be  traced  to  a  tumour  within  the  cranium:  its 
presence  may  be  first  shown  by  the  occurrence  of  local  paralysis  of  one  of  the 
cranial  nerves,  produced  simply  by  pressure  on  its  tract;  hence  it  was  said  that 
the  cause  of  local  paralysis  had  no  necessary  connexion  with  the  nerve-centres. 


PARAPLEGIA.'  175 

In  such  a  case  the  effect  of  the  tumour  within  the  cranium  is  just  the  same  as  it 
would  have  been  had  it  pressed  on  the  nerve  after  it  had  emerged  from  the  skull. 
"When  it  lias  attained  some  size,  it  may  destroy  a  portion  of  the  brain  in  which  seve- 
ral nerves  take  their  origin,  causing  paralysis  of  each,  and  then  we  have  a  case  of 
partial  hemiplegia — no  longer  one  of  local  paralysis.  Supposing  that  more  than 
one  nerve  were  paralyzed  by  pressure,  the  case  would  in  reality  be  one  of  com- 
pound local  paralysis;  yet  we  should  not  be  wrong  in  assigning  to  it  an  intra- 
cranial cause  which  is  all  that  diagnosis  can  assert  with  any  degree  of  confidence. 
It  does  not  appear  that  such  tumours  can  by  their  mere  size  produce  more  gene- 
ral hemiplegia.  When  this  occurs  it  almost,  certainly  depends  on  the  coincidence 
of  inflammation,  which  has  led  to  softening  of  the  brain  or  effusion  of  serum.  The 
oulv  possible  exception  is  when  the  pressure  is  excited  on  a  portion  of  the  me- 
dulla oblongata,  and  then  paraplegia  is  the  usual  if  not  the  invariable  result. 

By  far  the  most  common  cause  of  hemiplegia  is  extravasation  of  blood  in  the 
hemisphere  of  the  brain  opposite  to  the  side  of  the  body  affected;  but  why  this 
event  causes  in  one  case  both  apoplexy  and  paralysis,  in  another  apoplexy  alone, 
and  in  a  third  only  hemiplegia,  we  are  not  always  able  to  determine.  It  is  to  be 
remembered  that  while,  on  the  one  hand,  hemiplegia  does  not  necessarily  follow 
on  apoplexy,  so,  on  the  other,  its  continuance  after  consciousness  is  restored  must 
not  be  taken  as  proving  that  the  fit  has  been  of  the  nature  of  sanguineous  apo- 
plexy :  because  it  is  sometimes  dependent  on  effusion  of  serum,  when  one  lateral 
ventricle  is  more  distended  than  the  other.  Extravasation  of  blood  in  the  brain 
is  so  often  found  associated  with  disease  of  the  heart  and  arteries,  that,  apart  from 
any  consideration  of  causality,  the  discovery  of  valvular  lesion,  or  hypertrophy, 
affords  strong  presumptive  evidence,  in  cases  of  hemiplegia,  that  they  belong  to 
this  class  rather  than  to  serous  effusion  or  chronic  disease,  in  connexion  with 
this  subject  we  must  again  refer^p  the  plugging  up  of  an  artery  by  a  mass  of 
fibrine  detached  from  a  diseased  valve.  In  most  cases  the  paralysis  is  produced 
;  ^organization  of  brain  resulting  from  imperfect  nutrition;  but  it  also  appears 
to  be  sometimes  the  immediate  effect  of  the  stoppage  of  the  supply  of  blood,  when 
the  symptoms  are  necessarily  more  quickly  developed  than  in  the  other  instance: 
but  neither  present  the  character  of  rapidity  belonging  to  extravasation,  and  in 
neither  is  there  anything  like  an  apoplectic  attack. 

§  2.  Paraplegia. — Rarely  a  sudden  seizure  except  after  injury 
of  the  spine,  it  is  but  seldom  dependent  on  cerebral  disease;  in  both 
respects  it  stands  in  complete  contrast  to  hemiplegia.  As  in  hemi- 
plegia, however,  the  power  of  movement  is  generally  more  affected 
than  the  sensibility;  but  loss  of  the  one  seldom  exists  without  par- 
tial failure  of  the  other.  Its  characteristic  is  that  it  affects  both 
sides  of  the  body  symmetrically,  although  not  necessarily  to  the 
same  degree.  Its  history  points  out  its  more  or  less  gradual  de- 
velopment, the  occurrence  of  some  accident  or  injury  to  the  back, 
or  it  may  perhaps  afford  evidence  of  disease  of  the  brain.  It  ought 
always  to  be  ascertained  whether  there  be  any  deviation  from  the 
normal  condition  of  the  bones  of  the  spine,  or  any  point  at  which  a 
sudden  jar  or  blow  causes  more  pain  than  elsewhere;  we  have  then 
to  consider  how  high  the  condition  of  paralvsis  extends. 

a.  In  its  most  common  form,  the  disease  has  come  on  by  slow 
degrees,  observed  first,  perhaps,  in  one  leg,  and  soon  after  in  the 
other,  and  still  exhibited  to  a  greater  degree  in  the  limb  in  which  it 
was  first  felt,  but  extending  no  higher  than  the  loins;  it  has  been 
preceded  by  no  accident,  is  accompanied  by  no  distortion,  and  is 
entirely  without  pain.  The  patient  at  first  only  feels  some  weak- 
ness in  the  knees,  and  very  frequently  in  walking  experiences  a 


176  '    PARALYSIS. 

sensation  as  if  be  were  treading  on  soft  wool ;  the  muscular  sense 
is  soon  lost,  and  he  needs  to  look  at  his  feet  to  know  where  he 
Bteps;  gradually  the  paralysis  increases,  and  in  the  worst  cases  he 
is  at  length  reduced  to  such  a  state  that  he  has  no  power  even  to 
move  his  limbs  in  bed  except  with  the  assistance  of  his  hands,  and 
yet  the  upper  half  of  the  body  is  unaffected.  This  is  dependent  on 
a  condition  of  simple  atrophy  of  the  lower  part  of  the  cord;  there 
is  no  evidence  of  inflammation,  acute  or  chronic,  during  life,  no 
appearance  of  it  after  death:  nor  do  the  remedies  which  generally 
influence  the  progress  of  inflammation  show  any  power  over  this 
disease. 

b.  The  form  occurring  next  in  frequency  is  that  dependent  on 
injury  or  disease  of  the  spine — fracture  or  caries  of  the  bone,  and 
ulceration  of  the  intervertebral  cartilage.  Displacement  following 
on  these  causes  may  of  itself  give  rise  to  paralysis;  but  in  chronic 
cases  it  is  seldom  found  unaccompanied  by  evidence  of  inflammatory 
action:  we  may,  therefore,  for  all  practical  purposes,  class  along 
with  those  just  mentioned,  the  paralysis  consequent  on  concussion, 
which  may  result  at  once  from  the  accident,  and  be  perpetuated  by 
inflammation,  or  may  only  supervene  some  time  after  the  injury 
has  been  received.  Here  the  diagnosis  is  generally  facilitated  by 
the  history  of  an  accident  or  by  the  evidence  of  the  displacement 
which  generally  accompanies  fracture,  caries,  and  ulceration.  But 
it  sometimes  happens  that  the  ulceration  of  the  intervertebral  car- 
tilage sets  up  inflammation  in  the  membranes  of  the  cord  before 
displacement  occurs;  and  while  the  pain  on  movement,  and  stiffness 
of  the  back,  are  only  supposed  to  be  rheumatic,  symptoms  more  or 
less  distinct  of  this  inflammation  are  developed,  and  paralysis 
speedily  follows.  In  such  cases  accurate  diagnosis  depends  upon 
the  correct  appreciation  of  these  symptoms,  especially  with  re- 
ference to  the  seat  of  previous  pain  and  stiffness;  but  it  must  be 
confessed  that  the  knowledge  often  comes  too  late  to  be  of  much 
service  in  practice. 

c.  Idiopathic  inflammation  of  the  cord,  of  itself,  as  we  have  seen, 
a  comparatively  rare  disease,  may  give  rise  to  symptoms  of  para- 
lysis under  three  distinct  conditions:  they  maybe  only  the  evidence 
of  further  disintegration,  and  the  immediate  approach  of  death; 
they  may  remain  for  a  lengthened  period  in  consequence  of  chronic 
thickening  after  the  acute  symptoms  have  passed  by;  or  they  may 
arise  without  any  previous  acute  symptoms — the  inflammation  from 
the  first  prcsentino:  only  the  characters  of  a  subacute  or  chronic 
form.  An  exposure  to  cold,  the  occurrence  of  pain  in  the  back, 
and  the  comparative  suddenness  of  the  attack,  point  to  a  condition 
different  from  what  has  been  recognised  as  the  consequence  of 
atrophy.  The  resulting  paralysis  is  paraplegia,  but  there  is  very 
generally  a  considerable  difference  in  the  degree  to  which  the  limbs 
on  each  side  are  palsied. 

d.  The  pressure  of  a  tumour  on  some  portion  of  the  cord  may  also 


PARAPLEGIA.  177 

give  rise  to  paraplegia:  when  occurring  in  the  lower  region  of  the 
back,  with  no  external  evidence  of  its  presence,  it  i3  not  to  he  dis- 
tinguished from  cases  of  atrophy;  but  when  the  paralysis  has  conje 
on  gradually,  when  no  history  of  injury  is  obtained,  and  no  evidence 
of  distortion  exists,  when  the  patient  is  free  from  pain,  and  the  up- 
per extremities  are  partially  involved  as  well  as  the  lower,  good 
ground  exists  for  suspecting  the  existence  of  this  form  of  disease; 
when  the  breathing  is  also  interfered  with,  its  seat  is  probably  at 
the  base  of  the  brain,  and  it  may  be  expected  soon  to  prove  fatal. 

e.  Spinal  apoplexy  is  one  of  the  rarest  forms  of  disease  of  the 
cord.  The  symptoms  are  said  to  be  very  much  what  might  have 
been  anticipated  from  our  knowledge  of  cerebral  apoplexy:  vio- 
lent pain  in  the  region  of  the  efftfsion,  general  convulsions,  sud- 
den paralysis,  which,  in  place  of  affecting  one  side  of  the  body, 
occupies  its  lower  half  to  an  extent  determined  by  the  distance  of 
the  effusion  from  the  top  of  the  canal :  it  is  generally  unaccompanied 
by  coma,  and  proves  speedily  fatal. 

/.  General  paralysis.  This  is  the  only  form  affecting  both  sides 
of  the  body  which  has  its  seat  in  the  brain:  seldom  complete  un- 
til towards  its  close,  it.  is  marked  by  a  general  loss  of  muscular 
power,  an  occasional  difficulty  in  articulation,  tripping  over  or  stut- 
tering and  slurring  of  one's  words,  as  in  the  early  stages  of  intoxi- 
cation. It  is  seen  in  its  most  typical  form  in  the  paralysis  of  the 
insane,  where  along  with  the  gradual  abolition  of  the  muscular  pow- 
er, there  is  a  correspondingly  gradual  loss  of  mental  consciousness, 
ending  in  perfect  fatuity;  it  is  usually  preceded  by  symptoms  of 
alienation  of  mind  having  more  or  less  the  character  of  exaltation 
of  ideas:  the  patient  imagines  that  he  has*  acquired  an  enormous 
fortune;  or  the  quiet,  steady  man  of  business  becomes  suddenly  gay 
and  extravagant;  the  delusion  seems  always  to  have  the  character 
of  happiness  and  contentment. 

Pathological  anatomy  is  not  yet  sufficiently  advanced  to  point  out 
in  all  such  cases  what  are  the  actual  changes  in  structure  on  which, 
the  disease  depends,  the  brain  being  found  in  very  various  states 
after  death. 

A  corresponding  form  of  disease  exists  without  the  accompani- 
ment of  insanity,  in  which  it  is  also  quite  impossible  to  predict  the 
actual  lesion  that  will  be  discovered;  and  though  in  some  rare  cases 
no  appreciable  change  of  structure  can  be  detected,  yet  their  whole 
character  warrants  us  in  assigning  disease  of  the  brain  as  their 
cause.  The  consistency  of  the  affection,  its  extension  to  one  or  other 
or  both  of  the  upper,  as  well  as  the  lower  extremities,  makes  it  pro- 
bable that  the  seat  of  disease  is  above  the  spinal  column  ;  and,  having 
satisfied  ourselves  that  the  vertebrse  of  the  neck  are  free  from  dis- 
ease or  distortion,  our  next  step  is  to  analyze  with  care  the  condition 
of  the  cranial  nerves:  deafness,  unequal  action  of  the  pupils,  stra- 
bismus, &c,  are  to  be  taken  as  evidence  of  disease  in  the  cranium. 
It  is  worthy  of  remark  that,  while  these  nerves  are  affected  only  on 
12 


178  PARALYSIS. 

one  side,  and  one  arm  is  perhaps  decidedly  weaker  than  the  other, 
the  legs  are  usually  equally  paralyzed.  The  paralysis  is  sometimes 
coincident  with  a  condition  of  spasm  which  aftbrds  pretty  conclusive 
evidence  that  the  disease  is  situated  in  the  hrain  itself. 

Its  progress  is  generally  very  slow,  and  the  failure  in  muscular 
power  may  vary  greatly  in  intensity  in  different  parts  of  the  body, 
being  generally  most  complete  where  its  existence  was  first  recog- 
nised. In  the  paralysis  of  the  insane,  the  defect  in  speech  is  gene- 
rally that  which  is  first  observed;  in  other  cases  this  is  not  so,  but 
its  existence  is  always  very  important  in  diagnosis.  The  absence  of 
any  other  indication  of  disease  besides  loss  of  power,  in  some  in- 
stances, has  led  to  their  being  mistaken  for  cases  of  listeria  or 
hypochondriasis. 

g.  Paralysis  agitans:  although  clearly  not  belonging  to  the  class 
paraplegia,  the  few  remarks  to  be  made  on  this  disorder  will  best 
follow  the  description  of  general  paralysis.  There  is  no  evidence 
of  brain  disease ;  the  intellectual  faculties  are  unimpaired,  the  cranial 
nerves  are  not  liable  to  be  implicated;  indeed,  it  is  not  proved  that 
its  seat  is  in  the  nerves  themselves,  but,  like  chorea,  it  consists  in 
pome  disturbance  of  the  relation  between  nervous  influence  and  mus- 
cular movement;  there  is  no  anaesthesia.  It  is  chiefly  a  disease  of 
old  age,  comes  on  gradually  with  shaking  of  the  head  or  of  the  ex- 
tremities; these  are  indeed  its  only  diagnostic  features:  it  is  occa- 
sionally left  as  the  result  of  convulsions  in  infancy. 

An  analogous  disease  is  seen  in  the  tremor  of  those  subjected  to 
the  constant  action  of  mercurial  vapour.  The  tremor,  in  this  case, 
is  only  excited  by  voluntary  muscular  movement,  the  individual  at 
other  times  being  perfectly  still;  and  its  seat  is  most  probably  in 
the  nervous  system,  as  it  sometimes  presents  the  phenomena  of 
wakefulness  and  delirium.  It  is  one  of  the  examples  of  slow  poi- 
soning mentioned  in  an  earlier  part  of  this  volume. 

In  all  the  conditions  just  referred  to  we  are  very  much  at  a  loss  in  attempting 
to  explain  the  relation  of  the  phenomena  to  change  of  structure  in  the  nervous 
system.  This  difficulty  is  much  increased  by  the  fact  that,  whatever  be  the  form 
of  lesion,  and  however  local  and  limited  in  its  nature,  we  have  the  same  general 
result  of  paralysis  affecting  both  sides  of  the  body  alike:  and  therefore  practically 
the  important  considerations  in  paraplegia  are  limited  to  the  recognition  of  acute 
and  chronic  disease,  and  caries  or  injury  of  bone.  When  any  doubt  is  entertained 
with  regard  to  the  reality  of  partial  paraplegia,  it  may  be  always  solved  by  ob- 
serving with  due  care  the  mode  in  which  the  feet  are  set  down  in  attempting  to 
walk:  there  is  an  indescribable  uncertainty  about  the  gait  of  a  paraplegic  which 
imposture  can  never  successfully  imitate. 

§  3.  Local  Paralysis. — It  has  been  already  explained,  in  speak- 
ing of  hemiplegia,  that  this  appellation  is,  in  strictness,  confined  to 
cases  of  paralysis  not  having  a  central  origin;  when  it  depends  on 
loss  of  nervous  influence,  the  affection  of  the  nerve  is  located  some- 
where after  it  has  emerged  from  the  cerebro-spinal  axis.  Due  re- 
gard to  the  extent  and  special  distribution  of  the  affection,  and  know- 
ledge of  the  anatomy  of  the  nervous  system,  form  the  groundwork 


LOCAL    PARALYSIS.  179 

for  the  diagnosis'  of  local  paralysis;  it  is  limited  to  the  organ  which 
some  particular  nerve  supplies.  The  cranial  nerves,  issuing  singly 
from  the  brain,  afford  the  most  frequent  examples ;  thus  we  have 
amaurosis,  ptosis  of  one  eyelid,  anaesthesia,  or  palsy  of  one  side  of 
the  face,  &c.  In  all  such  cases  we  have  to  assure  ourselves  well 
that  no  other  cranial  nerve  is  similarly  affected,  because,  when  more 
than  one  is  implicated,  there  is  good  ground  for  believing  not  only 
that  the  lesion  is  within  the  cranium,  but  that  it  probably  also  in- 
volves the  brain  itself.  In  the  case  of  the  fifth  and  seventh  nairs, 
where  contiguity  or  admixture  of  fibres  of  different  kinds  exists,  the 
relations  of  paralysis  of  sensation  and  motion  are  sometimes  such, 
that  we  can  define  the  exact  portion  of  the  nerve  in  which  the  dis- 
ease is  seated.  Ambiguity  is,  to  a  certain  extent,  in  many  instances 
unavoidable;  because  while,  on  the  one  hand,  some  very  slight 
disease  within  the  cranium  may  produce  local  paralysis  and  nothing 
more,  it  is  equally  true,  on  the  other,  that  this  form  of  palsy  may 
be  the  first  manifestation  of  serums  disorganization. 

Pressure  of  a  tumour  on  the  brachial  plexus,  or  upon  the  crural 
nerve,  may  give  rise  to  symptoms  of  palsy  and  anaesthesia  more  or 
less  complete  in  the  limbs  to  which  they  are  distributed :  a  not  unfre- 
quent  instance  of  this  condition  is  the  numbness  of  the  legs  during 
pregnancy. 

Some  forms  of  local  paralysis  are  more  directly  connected  with 
the  muscular  structure  than  with  the  nerve  by  which  it  is  supplied. 
This  condition  is  met  with — especially  affecting  the  extensors  of 
the  forearm — in  lead  palsy,  but  also  involving  to  a  less  degree  the 
flexors.  The  colic  which  usually  precedes  the  affection  of  the  fore- 
arm, is  probably  caused  by  corresponding  paralysis  of  the  muscular 
coat  of  the  intestines. 

Drop-wrist  is  also  occasionally  met  with  in  over-worked,  half- 
starved  tailors  and  needlewomen,  without  colic,  without  blue-line, 
or  any  evidence  of  lead  poison,  and  would  seem  to  be  produced  by 
the  forced  and  long-continued  action  of  ill-nourished  muscles. 
Similarly,  an  over-strain  of  muscle,  on  perhaps  only  one  occasion, 
J3  sometimes  followed  by  loss  of  power.  Paralysis  of  the  bladder 
from  distention  affords  a  ready  example. 

Another  cause  of  local  paralysis,  which,  in  the  end,  becomes 
general,  should  be  mentioned — viz.,  fatty  degeneration.  Its  patho- 
logical relations  are  not  understood;  but  weakness  and  wasting  of 
one  muscle  after  another,  proceeding  in  a  direction  which  does  not 
necessarily  follow  the  anatomical  relations  of  the  nervous  system, 
may  be  suspected  to  be  due  to  this  change;  it  is  not  possible  to  give 
any  definite  rule  for  its  diagnosis. 

The  history  of  the  case,  as  has  been  already  remarked,  serves  to 
exclude  instances  in  which  local  paralysis  is  the  last  remnant  of  a 
more  general  affection,  or  the  only  effect  of  an  apoplectic  attack; 
these  evidently  belong  to  hemiplegia.  In  other  cases  it  points  out, 
when  the  disease  has  come  on  suddenly,  what  has  been  the  exciting 


180  PARALYSIS. 

cause;  or  it  indicates,  by  the  slow  supervention  "of  the  affection, 
that  it  is  due  to  some  condition  of  long  standing.  Such,  for  ex- 
ample, is  the  history  of  colic. 

Local  paralysis  is  not  generally  a  disease  of  grave  import:  it  is 
much  more  so  when  the  cranial  nerves  are  the  seat  of  the  affection 
than  when  spintil  nerves  only  are  implicated;  and  among  these  con- 
siderable differences  exist.  Facial  paralysis,  coming  on  after  expo- 
sure to  cold,  is  one  of  the  least  important.  Amaurosis  is  a  very 
distressing  disease  to  the  patient;  but  ptosis  is  a  symptom  of  much 
more  serious  consequence  in  the  mind  of  the  physician.  Strabismus 
in  childhood,  after  eclampsia,  is  common,  and  not  of  much  conse- 
quence ;  while  in  the  adult  its  presence  is  of  evil  augury,  when  of 
recent  occurrence.  But,  as  before  remarked,  the  coexistence  of 
affection  of  two  distinct  nerves  (e.  g.,  facial  palsy  with  strabismus) 
gives  most  cause  for  serious  apprehension;  or  the  concurrence  of 
any  of  them  singly  with  symptoms,  however  obscure,  which  can  be 
traced  in  any  way  to  disease  of  the  brain. 

Loss  of  power  is  more  definite  in  its  indications  than  loss  of 
sensation,  inasmuch  as  the  one  is  an  objective,  the  other  a  subjec- 
tive phenomenon;  but  yet  even  loss  of  power  may,  to  a  certain  ex- 
tent, be  exaggerated,  if  not  wholly  simulated,  by  the  imaginings  of 
the  patient,  when  the  paralysis  is  incomplete;  and  such  cases  are 
always  more  difficult  of  diagnosis  than  when  the  power  of  motion 
is  entirely  lost.  Patients  often  speak  of  numbness  when  they  do 
not  mean  anaesthesia  at  all;  there  is  no  loss  of  feeling,  but  perhaps 
a  sensation  of  tingling,  or  formication,  to  which  the  name  is  ap- 
plied. Such  cases  are  rather  to  be  regarded  as  an  indistinct  form 
of  neuralgia,  than  as  local  paralysis. 

The  bearing  of  diagnosis  on  treatment  in  all  cases  of  local  para- 
lysis, may  be  summed  up  in  the  discovery  of  its  cause,  whether  that 
be  revealed  by  the  history  of  the  case,  or  can  be  gathered  from  a 
knowledge  of  the  portion  of  the  nerve  which  is  the  seat  of  lesion, 
and  a  consideration  of  the  structures  immediately  surrounding  it, 
in  so  far  as  they  may  interfere  with  the  transmission  of  volition 
and  sensation  through  the  nerve  fibre. 


181 


CHAPTER  XVI. 

NEURALGIA. 

Its  place  in  Classification — Distinguished  from  Pain — Inflamma- 
tion—  General  Pain — Local  Pain — Irritation — Neuralgia  'pro- 
per.— §  1,  Tic  Douloureux — §  2,  Hemicrania — §  3,  Sciatica — 
§  4,  Angina  Pectoris — §  5,  Spinal  Neuralgia. 

The  term  neuralgia  is  one  which  only  serves  to  remind  us  of  the 
limited  range  of  our  knowledge:  had  we  attained  to  a  perfect  pa- 
thology, it  would  find  no  place  in  a  systematic  classification  of  dis- 
ease, except  as  a  symptom.  In  itself  a  mere  sensation  dependent 
on  a  variety  of  causes,  we  are  yet  forced  very  often  to  rest  satisfied 
with  the  knowledge  of  its  existence,  without  being  able  to  trace  it 
backward  to  its  true  source  in  the  causality  of  disease;  and  at  the 
same  time  its  very  vagueness  too  often  serves  as  a  cloak  for  igno- 
rance, or  furnishes  a  ground  for  deception.  It  is  exposed  to  all 
the  difficulties  in  investigation  which  are  inseparable  from  merely 
subjective  phenomena,  and  there  are  few  indications  by  which  we 
can  correct  an  opinion  we  are  driven  to  form  merely  upon  the  pa- 
tient's own  statement:  even  when  convinced  that  there  is  no  exag- 
geration  or  deception,  we  are  still  so  ignorant  of  the  changes  in 
nervous  structure,  that  if  we  be  able  to  prove  by  post-mortem  evi- 
dence that  there  has  been  no  other  cause  for  the  pain,  we  must  still 
rest  satisfied  with  the  fact  that  it  has  been  felt,  and  with  the 
expression  that  it  was  neuralgia. 

One  point  is  perhaps  not  sufficiently  attended  to  in  the  employ- 
ment of  the  term,  that  while  in  truth  all  pain  is  perceived  by  the 
nerves,  and  in  that  sense  is  seated  in  the  nerve,  yet  all  pain  ought 
not  to  be  called  neuralgia.  The  true  distinction  between  the  two 
is  that  in  the  one  instance  the  sensation  is  produced  by  some  irrita- 
tion acting  locally  on  the  terminal  filaments  of  the  nerves  which 
are  the  normal  recipients  of  it,  while  in  the  other  it  was  caused  by 
something  affecting  the  trunk  of  the  nerve, — that  bundle  of  fibres, 
large  or  small,  lying  within  the  neurilemma,  which  in  a  state  of 
health  does  not  receive,  but  transmit  the  sensation:  consequently, 
neuralgia  properly  so-called  affects  all  the  sensitive  branches  uni- 
ting to  form  the  trunk  on  which  the  irritation  acts,  and  pain  is  felt 
sometimes  distinctly  to  the  terminal  filaments,  sometimes  vaguely 
in  the  course  of  the  ramifying  fibres.  As  in  paralysis,  a  know- 
ledge of  the  parts  over  which  pain  is  distributed,  and  of  the  ana- 
tomical relations  of  the  nerves,  will  best  assist  us  in  distinguishing 
between  neuralgia  and  local  pain.  When  two  distinct  parts  of  the 
body,  having  no  nervous  communication  with  each  other,  are  both 


182  NEURALGIA. 

the  scat  of  pain,  the  presumption  is  very  strong  that  they  are  not 
simultaneously  affected  with  neuralgia;  when  all  the  structures 
supplied  by  one  nerve  are  painful,  it  is  highly  improbable  that  each 
should  be  influenced  by  a  local  cause;  when  one  form  of  structure 
only  is  affected,  we  are  led  to  suspect  that  there  must  be  some 
change  in  that  to  account  for  the  suffering,  rather  than  an  affection 
of  the  nerve:  these  rules  are  well  exemplified  in  the  diagnosis 
between  rheumatism  and  neuralgia. 

At  the  risk  of  repetition,  I  must  again  remark  that  if  there  be  a  distinction  be- 
tween pain  and  neuralgia,  it  is  still  greater  between  all  sorts  of  pain  and  inflam- 
mation. Pain  is  the  expression  of  irritation  of  nerve  matter,  and  nothing  more: 
in  different  individuals  it  has  a  very  different  signification;  some  are  intolerant  of 
pain,  and  generally  use  big-sounding  words  to  express  it — it  is  terrible,  dreadful, 
intense — when,  in  reality,  there  is  little  derangement;  some  are  callous  and  indif- 
ferent, and  will  scarcely  admit  that  they  suffer  pain,  when  such  disorder  is  present 
as  can  scarcely  exist  without  it.  Perhaps  the  best  criterion  of  the  reality  and 
amount  of  pain  experienced  by  the  patient,  is  when  it  produces  an  expression  of 
anxiety  and  pinching  of  the  features;  this  is  something  quite  different  from  the 
eyebrows  being  knitted  together  in  a  frown,  and  is  equally  distinct  from  the  sad- 
ness and  tear-shedding  aspect  of  hysteria:  it  is  one  of  the  points  in  the  physiog- 
nomy of  disease  which  has  to  be  learned  by  the  student. 

It  may  be  stated  generally  that  pain  accompanying  inflammatory  action  is  lc--s 
noticed  by  the  patient  than  that  attending  nervous  disorders,  whether  functional 
or  neuralgic.  The  pain  of  inflammation  is  described  as  acute,  darting,  or  stab- 
bing, in  opposition  to  dull,  aching  pain;  and  that  of  suppuration  as  a  throbbing 
pain :  but  the  whole  vital  functions  are  so  deranged  that  the  attention  is  less  en- 
grossed by  it,  and  it  less  frequently  forms  the  chief  subject  of  complaint:  perhaps, 
too,  it  is  not  so  coustant;  and  as  it  is  aggravated  by  pressure,  it  is  also  in  some 
measure  dependent  on  movement,  and  is  therefore  less  felt  in  perfect  quietude. 
Inflammations  of  various  organs  differ  very  materially  in  the  amount  of  pain  they 
cause;  the  bones,  joints,  and  ligaments,  the  skin,  and  the  serous  membranes,  be- 
come the  seat  of  much  greater  pain  when  inflamed  than  the  mucous  membranes 
and  the  viscera.  For  example,  in  peritonitis,  acute  rheumatism,  gout,  carbuncle, 
the  pain  is  generally  a  prominent  symptom;  in  inflammations  of  the  liver,  the 
bowels,  and  the  bladder,  it  is  much  less  noticeable:  again,  a  dyspeptic  headache 
is  much  more  complained  of  than  the  pain  of  the  most  intense  meningitis;  in  acute 
pleurisy,  the  patient  dare  not  cough  or  draw  a  deep  breath;  and  yet,  till  his  atten- 
tion be  drawn  to  it,  the  pain  may  be  the  last  thing  he  speaks  of.  Corroding  can- 
cer, again,  affords  an  example  of  pain  without  inflammation,  which  is  very  severe 
and  lancinating,  and  yet  patients  occasionally  present  themselves  who  suffer  very 
little  while  labouring  under  that  dreadful  malady. 

In  Chapter  II.  (p.  33)  allusion  was  made  to  the  lessons  taught  by 
the  duration  of  pain ;  when  it  was  stated  that  its  importance  in 
cases  of  long-standing  is  to  be  measured  by  its  effects,  and  that 
when  of  recent  date,  it  is  a  symptom  of  but  little  consequence  in 
persons  who  have  been  long  ailing,  while  their  general  health  is  not 
seriously  undermined.  These  considerations  suffice  to  show  the 
necessity  of  inquiring  into  the  patient's  previous  history,  and  in 
doing  so  we  shall  often  find  that  the  precursory  symptoms,  or  the 
circumstances  which  have  seemed  to  give  rise  to  it,  throw  great 
light  on  its  causes.  General  pain,  by  which  is  meant  pain  or 
aching  not  limited  to  particular  organs,  but  irregularly  distributed 
over  the  body,  is  commonly  an  indication  of  general  disorder;  such 


NEURALGIA.  18 


.-> 


as  we  have  already  studied  in  what  are  called  blood-diseases,  fevers, 
rheumatisms,  even  ansemia:  it  may  be  muscular,  or  confined  to  the 
joints,  to  the  bones  (<?.  g.,  rheumatic  periostitis,)  or  to  the  nervous 
system,  with  headache  and  pain  in  the  back.  These  varieties  in 
its  manifestation,  comprising  the  individual  elements  of  which  the 
sum  of  general  pain  is  composed,  lead  us  by  analysis  to  the  various 
diseases  and  disorders  in  which  we  have  already  met  with  it  as  one 
of  the  symptoms.  Another  form  of  general  pain  is  somewhat  ana- 
logous in  character  to  neuralgia;  it  is  referred  to  the  sensitive  fila- 
ments of  the  nerves,  but  has  its  real  seat  in  some  portion  of  the 
cerebro-spinal  axis,  and  is  caused  by  disease  of  or  pressure  upon 
some  portion  of  the  central  organs;  it  is  often  very  irregular  in 
its  manifestation,  and  is  of  great  importance  when  associated,  as  it 
is  sooner  or  later,  with  spasm  or  paralysis:  occasionally  it  is  com- 
plained of  in  parts  which  have  lost  some  degree  of  their  ordinary 
sensibility.  Apart  from  such  corroborative  symptoms,  there  is 
nothing  in  the  pain  itself  to  distinguish  its  cause;  when  more  limit- 
ed in  its  distribution,  it  is  apt  to  be  confounded  with  neuralgia; 
when  diffuse  and  irregular,  it  resembles  muscular  rheumatism. 

Local  pain  is  either  direct  or  sympathetic:  when  accompanied 
by  a  febrile  state,  it  is  always  referrible  to  some  congestion  or 
inflammation;  without  fever,  it  is  either  dependent  on  some  chronic 
ailment  of  the  part,  or  it  must  be  regarded  simply  as  neuralgia. 
The  first  inquiry,  therefore,  is  whether  there  be  any  alteration  in 
the  function,  normal  condition,  or  nutrition  of  the  part  in  which 
pain  is  complained  of;  next,  whether  any  ailment  exist  elsewhere 
of  which  such  pain  is  known  to  be  sympathetic. 

Examples  of  such  affections  are  found  in  disorder  of  the  liver,  being  frequently 
associated  with  pain  in  the  right  shoulder;  nephralgia,  especially  calculus  of  the 
kidney,  causing  pain  in  the  thigh,  groin/or  testicle;  irritation  of  the  bladder  being 
referred  to  the  meatus  urinarius;  disease  of  the  womb,  leucorrhoeal  and  other  dis- 
charges, being  accompanied  by  pain  across  the  sacrum;  disease  of  the  hip-joint 
being  often  indicated  by  pain  in  the  knee,  &c.  Some  practitioners  have  recently 
attempted  to  substitute  a  theory  of  sympathetic  or  perhaps  reflex  pain,  connected 
with  the  uterus  and  ovaries,  for  that  of  spinal  irritation,  as  affording  an  explana- 
tion of  some  of  the  anomalous  pains  of  hysterical  females.  This  wants  confirma- 
tion, and  will  in  all  probability  be  found  as  baseless  as  the  spinal  irritation  theory. 

We  must  not  overlook  the  consideration  that  direct  pain  in  local  inflammation 
is  aggravated  by  movement  or  pressure,  and  is  indeed  sometimes  only  spoken  of 
as  produced  by  such  circumstances;  bearing  in  mind,  at  the  same  time,  the  ex- 
aggeration of  this  fact  exemplified  in  the  tenderness  of  hysteria. 

Should  careful  inquiry  reveal  no  definite  cause  for  local  pain,  we 
must  be  content  with  the  terms  neuralgia  and  irritation;  not  that 
they  are  in  themselves  satisfactory,  but  they  serve  to  distinguish 
conditions  beyond  which  we  cannot  at  present  penetrate.  Patients 
generally  are  unacquainted  with  the  situation  and  distribution  of 
nerves,  and  therefore  we  may  fairly  assume  that  there  is  more  of 
reality  and  less  of  imagination  in  pain  described  as  following  the 
known  course  of  some  nerve,  than  in  that  which  is  anomalous  and 
irregular.     But  while  remembering  that  it  may  be  the  effect  of 


184  NEURALGIA. 

imagination,  or  may  be  simply  imposture,  and  while  all  pain  unac- 
companied by  local  lesion  is  very  liable  to  exaggeration,  yet  we 
know  that  irritation  really  does  occur,  and  does  give  rise  to  pain, 
ami  therefore  it  must  not  be  ignored  only  because  we  cannot  find 
out  its  cause.  Examples  of  local  irritation  are  found  in  toothache, 
earache,  muscular  rheumatism,  the  effects  of  a  strain,  as  well  as  in 
painful  digestion,  painful  menstruation,  &c.  An  hysterical  or  chlo- 
rotic  female  has  almost  always  pain  in  the  left  side ;  this  is  proba- 
bly due  to  the  liability  to  excited  action  of  the  heart,  present  in 
such  cases,  associated,  as  it  commonly  is,  with  flatulent  distention 
of  the  stomach.  When  local  irritation  has  a  persistent  character 
we  may  conclude  that  there  is  some  hidden  cause  for  its  presence. 

Pain  dependent  on  irritation  is  of  more  importance  when  accom- 
panied by  tenderness  on  pressure:  so  true  is  this,  that  even  sympa- 
thetic pain,  when  severe,  will  produce  tenderness  in  the  part  where 
the  pain  is  felt,  although  we  know  certainly  that  the  seat  of  the 
disease  and  the  cause  of  the  pain  is  located  elsewhere.  This  obser- 
vation must  of  course  be  taken  with  the  limitation  that  it  is  not 
hysterical  tenderness  accompanying  hysterical  irritation. 

It  is  sometimes  quite  impossible  to  determine  the  circumstances 
which  give  rise  to  this  nervous  irritation;  its  cause,  for  example, 
may  be  inseparably  bound  up  with  derangement  of  stomach  or  dis- 
order of  the  intestinal  canal,  while  its  effects  are  really  produced 
at  a  very  distant  part.  When  the  stomach  has  been  emptied  by 
vomiting,  or  the  primce  viae  cleared  out  by  a  brisk  purgative,  the 
pain  immediately  ceases.  In  such  circumstances,  as  Avell  as  in 
those  more  usually  called  sympathetic,  there  is  probably  something 
of  a  reflex  action ;  and  to  them  the  name  of  neuralgia  might  with 
some  propriety  be  applied:  it  seems  better,  however,  to  confine  it 
to  cases  in  which  there  is  some  actual  impression  on  the  nerve- 
trunk,  producing  sensations  in  the  branches.  Though  not  limited 
to  any  particular  nerves,  there  are  a  few  in  which  it  is  more  com- 
monly met  with  than  in  others,  and  to  them  distinct  names  have 
been  applied. 

§  1.  Tie  Douloureux. — This  disorder  usually  affects  the  branches 
of  the  fifth  pair;  it  is  described  as  a  darting  pain  which  thrills 
alon<<;  the  course  of  the  nerve  to  its  remotest  branches.  Sometimes 
limited  to  one,  sometimes  extending  to  all  of  the  main  divisions  of 
the  nerve,  its  momentary  shock  seizes  the  individual  without  warn- 
ing under  a  variety  of  exciting  causes.  The  pain  is  intense,  though 
transient,  leaving  an  aching  for  some  few  minutes  after  it  has 
passed;  it  recurs  again  and  again  on  the  occasion  of  any  fresh 
stimulus,  whether  speaking,  eating,  a  draught  of  air,  or  a  touch,  or 
even  without  apparent  cause.  Its  associations  are  so  numerous  as 
to  defy  classification:  it  is  enough  here  to  say,  that  in  many  in- 
stances treatment  directed  to  correcting  general  disordered  states 
of  system  is  successful  in  its  removal;  and  we  are  therefore  called 


HEMICRANIA — SCIATICA — ANGINA    PECTORIS.       185 

upon  to  investigate  all  the  correlative  symptoms,  not  as  an  aid  to 
diagnosis,  which  is  generally  only  too  unmistakeable,  but  as  a  guide 
to  rational  treatment.  The  most  intractable  cases  are  those  in 
which  there  is  coexisting  disease  at  the  root  of  the  nerve ;  they 
present  to  us  the  same  problem  as  epilepsy,  so  difficult  of  solution, 
why  an  abiding  cause  of  irritation  should  only  manifest  itself  in 
paroxysms. 

§  2.  Hemicrania. — Much  more  diffuse  than  tic,  its  paroxysms 
are  not  nearly  so  intense,  but  they  are  of  very  much  longer  dura- 
tion: like  it,  they  very  generally  entirely  subside  for  a  time,  to 
return  at  no  long  interval;  but  in  this  disease  there  is  very  fre- 
quently a  marked  regularity  or  periodicity  in  the  recurrence ;  in 
such  cases  its  popular  name  is  brow  ague.  Its  situation  is  not  so 
much  in  the  face  and  the  course  of  the  fifth  nerve,  as  generally 
over  one  side  of  the  head,  referred  especially  to  the  forehead,  and 
frequently  affecting  the  eyeball.  When  associated,  as  it  often  is, 
with  a  debilitated  or  exhausted  condition  of  the  body,  it  is  less  dis- 
tinctly periodic,  and  easily  curable  by  means  calculated  to  remedy 
the  general  health;  in  its  purely  intermittent  form  it  is  only  a 
manifestation  of  malarious  poison. 

§  3.  Sciatica. — It  is  very  often  difficult  to  make  out  whether  a 
patient  be  suffering  from  chronic  rheumatism  or  sciatica;  but  the 
distinction  in  such  cases  is  of  less  importance,  as  this  form  of  neu- 
ralgia is  very  frequently  of  rheumatic  origin.  In  a  well-marked 
case,  the  pain  is  described  as  extending  from  the  sciatic  notch  down 
the  back  of  the  thigh  and  leg ;  and  the  effect  of  counter-irritants 
in  its  treatment  seems  to  prove  that  the  pain  is  due  to  subacute 
inflammation  of  the  neurilemma.  But  it  is  often  much  more  diffuse ; 
and  then  it  is  quite  as  likely  that  the  ultimate  filaments  of  the  nerve 
are  the  seat  of  irritation,  as  its  main  trunk.  This  is  especially  the 
case  when  the  pain  is  more  sensibly  felt  in  the  proximity  of  the 
joints;  it  is  probable,  in  such  cases,  that  those  are  its  real  seat, 
although  not  spoken  of  by  the  patient,  whose  description  is  so  vague 
that  it  can  only  be  determined  by  the  effect  of  movement:  forced 
flexion  of  the  joints  is  always  painless  in  sciatica,  voluntary  motion 
gives  pain  alike  in  both  diseases.  In  sciatica  the  pain  is  not  in- 
creased, as  it  usually  is  in  rheumatism,  by  the  patient  bearing  his 
weight  on  the  limb :  local  disease  of  the  joints  can  hardly  lead  to 
any  perplexity,  as  pain  is  not  an  early,  and  rarely  an  urgent  symp- 
tom in  such  cases.  The  existence  of  previous  pain  in  other  joints 
or  limbs  would  lead  us  to  suspect  that  it  was  of  rheumatic  character, 
even  when  convinced  from  other  circumstances*that  the  case  Avas 
clearly  one  of  neuralgia. 

§  4.  Angina  Pectoris. — This  is  perhaps  the  best  place  to  consider 
a  disease  of  which  all  that  we  know  is  that  it  is  accompanied  by 


186  NEURALGIA. 

intense  pain,  referred  to  the  cardiac  region,  and  doubtless  expe- 
rienced  in  the  nerves  of  the  heart  itself;  while  it  also  sympatheti- 
cally extends  down  the  left  arm,  sometimes  as  far  as  the  termina- 
tions of  the  ulnar  nerve  in  the  last  two  fingers.  The  circumstances 
which  prove  its  cardiac  origin,  are  its  sudden  and  apparently  cause- 
less occurrence,  its  independence  of  feelings  of  dyspnoea,  the  sensa- 
tion of  extreme  faintness,  and,  what  is  sometimes  so  well  described 
by  the  patient,  a  sensation  as  if  the  heart  had  stood  still.  These 
points  are  quite  sufficient  to  establish  its  diagnosis;  and  as  yet  we 
must  rest  satisfied  with  the  knowledge  of  its  spasmodic  character. 

In  most  cases  of  angina,  disease  of  the  heart  exists;  sometimes 
such  as  may  be  detected  by  the  stethoscope,  frequently  of  such  a 
character  as  escapes  observation,  or  can  only  be  inferred  from 
general  indications,  such  as  fatty  disease  and  ossific  deposits,  espe- 
cially in  the  coronary  arteries.  There  can  be  no  question  that 
such  conditions  predispose  to  it;  but  neither  do  they  of  necessity 
produce  it,  nor  are  they  essential  to  it:  patients  with  organic  disease 
have  no  angina,  others  have  angina  in  whom  there  is  no  reason  to 
believe  that  the  heart  is  diseased.  This  leads  us  to  classify  it 
among  the  neuralgias  as  being  especially  characterized  by  spas- 
modic pain,  and  as  leaving  behind  it  after  death  no  definite  record 
of  its  existence. 

It  is  liable  to  be  confounded  with  the  palpitation  produced  by 
d}rspepsia,  and  especially  that  which  in  nervous  persons  accompanies 
flatulent  distention  of  the  stomach.  Such  a  mistake  can  only  occur 
with  those  who  are  hasty  in  their  conclusions,  and  who  do  not  in- 
quire accurately  into  the  mode  of  incursion  of  every  disorder:  the 
one  almost  always  makes  its  first  attack  during  exertion,  or  in  con- 
sequence of  sudden  and  violent  emotion;  the  other  most  generally 
awakes  the  patient  out  of  a  troubled  sleep,  and  has  been  preceded 
by  a  continuance  of  dyspeptic  symptoms.  Nor  do  the  amount  of 
anxiety  and  distress,  or  the  duration,  at  all  correspond  in  the  two 
affections;  the  one  is  momentary,  and  of  such  intensity  that  the 
patient  feels  he  could  not  survive  its  duration,  if  prolonged  for  ever 
so  short  a  time ;  the  other  is  much  less  violent,  and  more  con- 
tinuous. 

The  attack  of  angina  is  occasionally  closely  simulated  by  what' 
is  called  masked  gout,  especially  when  the  disease  is  retrocedent: 
in  the  latter  case,  the  fact  of  its  existence  in  the  joints,  perhaps 
only  the  day  before,  and  its  sudden  disappearance  having  been  al- 
most immediately  followed  by  the  spasmodic  pain,  sufficiently  cha- 
racterize it;  and  in  the  former,  the  previous  occurrence  of  extreme 
dyspeptic  symptoms,  and  irregular  pains,  a  gouty  history  and  di- 
athesis, as  well  as  Its  slower  incursion  and  longer  duration,  lead  us 
to  the  conviction  that  the  disease  is  not  angina,  and  will  probably 
serve  to  point  out  its  true  nature.  It  seems  almost  unnecessary  to 
add  that,  obscure  as  many  of  these  cases  of  masked  gout  undoubt- 
edly are,  true  diagnosis  is  most  essential  to  correct  treatment. 


SPINAL   NEURALGIA.  187 

§  5.  Spinal  Neuralgia. — Lumbago  has  been  already  mentioned 
as  one  of  the  more  severe  and  common  forms  of  muscular  rheu- 
matism: pain  in  the  back  has  been  referred  to  as  an  indication 
of  an  attack  of  smallpox,  and  as  not  uncommon  in  fever  gene- 
rally: it  is  also  an  accompaniment  of  irritation  of  the  kidney, 
and  is  sympathetic  of  uterine  disorder.  But  we  still  meet  with  pain 
in  the  back  which  cannot  be  referred  to  any  of  those  causes:  in 
very  many  cases  it  is  merely  one  of  the  forms  of  hysteria,  and  as 
such,  with  its  many  anomalous  characters,  its  irregular  manifesta- 
tions, and  its  power  over  the  imagination  of  its  victims,  has  given 
rise  to  many  false  theories,  and  to  much  pernicious  practice; 
nothing  can  be  more  deplorable  than  the  permanent  mischief  which 
has  frequently  ensued  from  confining  such  persons  to  a  recumbent 
posture,  till  the  best  advice  and  the  most  judicious  treatment  may 
fail  for  years  to  set  them  again  on  their  legs.  The  views  of  those 
who  ascribe  this  affection  to  irritation  within  the  spinal  canal, 
appear  to  me  most  unphilosophical  and  most  unsatisfactory.  We 
must,  indeed,  refer  it  to  what  has  been  distinguished  as  irritation, 
— a  condition  of  the  sensitive  extremities  of  the  nerves,  of  which  in 
reality  we  know  nothing;  but  it  is  assuredly  not  an  irritation  of 
nerve  centres  or  of  nerve  trunks. 

This  class  of  cases  is  deserving  of  careful  study,  in  order  that  we 
may  not  be  misled  by  them,  as  they  form  a  large  proportion  of  the 
nervous  affections  of  the  back :  their  diagnosis  is  based  upon  those 
general  features  which  mark  the  hysteric  tendency ;  long  ailment, 
without  serious  impairment  of  health;  inconsistency  between  sub- 
jective and  objective  phenomena;  excessive,  but  unreal  tender- 
ness; and  pain,  evidently  not  limited  to  one  nerve  or  one  set  of 
nerves,  unreasonably  excited  by  trivial  causes,  and  not  increased 
by  others,  except  the  patient  be  led  to  expect  that  it  ought  to  be. 
But  it  often  requires  great  care  to  discriminate  these  spurious  affec- 
tions from  the  pain  caused  by  disease  of  the  vertebra,  before 
alteration  in  form  and  direction  proves  the  presence  of  caries.  If 
any  one  character  more  than  another  can  serve  to  distinguish  them, 
it  is  that  a  sudden  jar  or  shock  to  the  spine  will  necessarily  increase 
the  pain  attendant  on  disease  of  bone. 

When  such  cases  are  eliminated,  only  a  very  few  remain  to  which 
the  name  of  neuralgia,  as  already  defined,  can  apply.  They  are 
very  generally  rheumatic  in  their  origin,  but  do  not  exhibit  in  any 
great  degree  the  character  usually  associated  with  rheumatism,  of 
being  aggravated  by  motion:  we  cannot  get  beyond  the  fact  of  local 
pain  limited  to  parts  supplied  by  a  single  set  of  nerves.  It  is  im- 
portant to  observe  whether  there  be  any  loss  of  ^ordinary  sensibility 
or  of  muscular  power,  as  such  circumstances  would  indicate  a  more 
serious  affection  than  simple  neuralgia. 


188 


CHAPTER  XVII. 

EXAMINATION   OF  THE   CHEST. 

Importance  of  Correct  Knowledge — its  Sources — §  1,  History  and 
General  Symptoms — Acute  and  Chronic  Disease — Pain — Indi- 
cations of  Fever — of  Emaciation — The  Breathing — Cough — 
Expectoration — §  2,  Physical  Signs — (a)  External  Appearances 
— {b)P  emission — its  Teaching — Sources  of  Error — (c)  Auscul- 
tation— its  Application — False  Nomenclature — How  Deductions 
are  to  be  drawn. 

In  the  ordinary  course  of  inquiry,  we  have  next  to  examine  the 
condition  of  the  organs  contained  in  the  chest;  and  in  order  to 
ensure  habits  of  accuracy  in  diagnosis,  the  student  should  make  a 
rule  under  no  circumstances  to  omit  it:  in  practice  he  may  subse- 
quently limit  himself  to  a  few  general  questions  with  regard  to 
cough,  dyspnoea,  or  palpitation,  and  the  existence  of  pain  or  of  ex- 
pectoration. If  the  answers  to  such  queries  be  unsatisfactory, 
further  inquiry  is  evidently  called  for ;  but  even  when  they  fail  to 
elicit  any  statement  indicating  the  presence  of  disease,  the  exa- 
mination of  the  chest  may  be  attended  with  the  most  important  re- 
sults: it  is  scarcely  too  much  to  say  that  diagnosis  would  be  less 
frequently  at  fault,  and  treatment  more  uniformly  beneficial,  if  it 
were  our  constant  practice  to  ascertain  the  leading  characters  of  the 
respiration  and  the  heart's  action  in  all  classes  of  disease,  just  as 
we  are  accustomed  to  look  at  the  tongue  and  feel  the  pulse.  A 
cursory  examination  at  least  serves  to  assure  us  that  there  is  or  is 
not  disease  of  much  amount,  while  a  more  careful  investigation  may 
bring  to  light  some  fact  which  will  in  great  measure  serve  to  ex- 
plain circumstances  previously  unintelligible. 

§  1.  History  and  G-eneral  Symptoms. — The  history  of  the  case 
sometimes  affords  but  little  information,  while  in  other  instances  it 
may  almost  alone  serve  as  the  basis  for  correct  diagnosis.  The 
duration  of  the  attack  at  once  separates  cases  of  recent  origin  from 
those  which  by  their  continuance  or  repetition  are  shown  to  be  more 
or  less  chronic:  from  the  date  of  the  first  deviation  from  health 
and  the  order  of  sequence  among  the  phenomena,  we  learn  whether 
pain  or  febrile  symptoms,  coryza  or  expectoration,  attended  its 
commencement,  or  the  cough  came  on  gradually ;  and  we  are  also 
enabled  to  place  by  themselves  cases  in  which  the  very  important 
fact  can  be  elicited  that  blood  has  been  occasionally  mixed  with  the 
sputa.  Any  past  illness,  directly  or  indirectly  bearing  on  disease 
of  the  chest,  should  be  noted,  because  it  may  show  that  the  symp- 
toms are  in  all  probability  secondary  on  disease  in  other  organs; 


EXAMINATION    OF    THE    CHEST.  189 

or  that  the  present  attack  has  been  preceded  by  others  of  the  same 
kind,  which  have  been  relieved  by  partial  or  complete  intermissions. 
In  the  present  condition  of  the  patient  we  have  to  consider  whe- 
ther the  general  symptoms  indicate  inflammatory  fever  or  hectic,  or 
freedom  from  any  febrile  disturbance;  the  pulse  must  be  especially 
noticed,  as  it  is  one  of  the  more  direct  signs  of  disease  of  the  heart. 
The  appearance  may  be  one  of  health  and  strength,  or  of  weakness 
and  emaciation :  the  aspect  may  betray  signs  of  anxiety,  as  caused 
by  pain  or  breathlessness:  the  colour  of  the  face  may  have  the 
dusky  hue  of  ill-ventilated  blood,  or  the  brilliancy  of  hectic.  We 
have  to  pay  regard  to  the  posture  which  disease  may  oblige  the 
patient  to  assume  for  the  relief  of  laboured  respiration ;  and  while 
listening  to  complaints  of  pain  or  discomfort,  we  watch  the  charac- 
ter of  the  breathing  and  cough,  with  regard  to  frequency  and  force, 
comparing  the  former  especially  with  the  quickness  and  power  of 
the  pulse;  it  is  also  important  to  ascertain  the  character  of  the 
expectoration. 

These  circumstances  may  point  either  to  disease  of  the  heart  or  of  the  lungs. 
The  history  of  the  former  is  generally  obscure,  the  origin  unknown  to  the  patient 
himself,  and  the  duration  extremely  uncertain;  and  it  is  perhaps  only  when  the 
pain  of  pericarditis  marks  the  commencement  of  that  disease,  that  any  definite 
information  is  gained. 

The  duration  of  the  different  affections  of  the  chest  varies  in  a  very  remark- 
able degree:  it  is  but  a  few  days  in  acute  inflammation;  in  chronic  bronchitis  and 
phthisis,  the  more  severe  symptoms  may  be  spoken  of  as  having  existed  for  some 
weeks;  there  have  been  probably  months  of  continuous  ailment  in  galloping  con- 
sumption; while  the  illness  may  have  lasted  for  years  in  chronic  phthisis,  emphy- 
sema, and  bronchitis,  and  in-  disease  of  the  heart,  during  which  the  patient's 
health  has  been  always  more  or  less  deranged.  At  the  same  time  it  will  con- 
stantly be  experienced  in  practice  that  very  serious  disorganization,  especially  in 
disease  of  the  heart,  must  have  been  proceeding  for  years,  without  any  conscious- 
ness of  its  existence  on  the  part  of  the  sufferer. 

Not  unfrequently  the  date  which  is  assigned  as  the  commencement  of  the 
attack  is  altogether  erroneous;  the  first  symptoms  have  not  been  observed,  or 
have  been  forgotten:  some  persons  speak  of  having  had  cough  as  long  as  they 
can  remember;  others  are  unable  to  recall  to  mind  the  colds  and  coughs  of  last 
winter;  and  a  false  date  is  worse  than  none  at  all:  but  it  is  not  without  value,  in 
a  diagnostic  point  of  view,  that  the  patient  is  unable  to  assign  a  date,  because  it 
indicates  the  insidious  approach  of  the  malady;  more  commonly  some  period  is 
named  at  which  it  is  alleged  that  cold  was  caught.  Beyond  this,  perhaps,  all 
inquiry  fails  in  getting  any  information;  the  points  of  greatest  importance  are 
the  existence  of  pain  and  fever  in  an  illness  of  recent  date,  and  the  occurrence  of 
hemoptysis  in  one  of  old  standing. 

In  the  history  of  antecedent  illnesses  we  are  sure  to  find,  when  the  symptoms 
of  chest  affection  are  primary,  and  the  attacks  repeated,  that  the  lungs  are  the 
organs  chiefly  implicated;  while  by  the  previous  occurrence  of  rheumatism  or 
dropsy  we  are  led  to  expect  disease  of  the  heart,  and  the  affection  of  the  lungs  is 
more  likely  to  be  subordinate  and  of  minor  importance.  When  confined  to  the 
respiratory  organs,  we  either  meet  with  severe  symptoms  of  occasional  occurrence, 
or  with  habitual  winter  cough;  the  patient  may  be  an  old  asthmatic,  or  may  have 
been  always  delicate:  latterly  he  may  have  lost  flesh  and  strength;  and  we  en- 
deavour to  contrast  his  present  state  with  what  we  can  gather  from  description  to 
have  been  his  usual  condition  of  health  prior  to  the  illness  under  which  he  is  now 
labouring. 

From  this  we  are  led  to  inquire  what  is  that  actual  state:  the  presence  or  ah- 


100  EXAMINATION    OF    THE    CHEST. 

sence  of  fever  will  be  indicated  by  the  skin,  pulse,  tongue,  &e.:  but  here  we  often 
•  with  the  adynamic  form  called  hectic,  in  which  the  rabidity  of  the  pulse  is 
nol  alwaya  accompanied  by  a  furred  tongue  or  a  hot  skin — at  one  time  it  is  dry 
and  burning,  at  another  it  is  bedewed  with  moisture  or  dripping  with  perspiration: 
cases  the  tongue  is  often  chapped,  peeled,  or  glazed,  and  the  bowels  tend 
arrhoea.     Heal  inflammation  of  the  lungs  (pleurisy  or  pneumonia.)  as  well  as 
pericarditis,  can  scarcely  have  place  without  the   coexistence  of  inflammatory 
fever.     Irregularity  of  pul.se  invariably  indicates  disease  of  the  heart:  its  frequency 
in  cases  clearly  tubercular  marks  the  distinction  between  the  acute  and  chronic 
type  of  phthisis:  an  habitually  quick  pulse  in  bronchitis  would  lead  to  the  suspi- 
cion of  tubercles,  when  there  is  no  other  proof  of  their  presence;  a  quiet  one 
may  tend  to  disprove  such  a  conclusion,  when  some  probabilities  are  iu  its  favour. 
The  absence  of  emaciation  is  often  at  once  taken  as  decisive  against  the  suppo- 
m  of  tubercular  disease:  but  neither  is  this  without  exception,  nor  is  the  con- 
verse absolutely  true  that  chronic  chest  ailment  with  emaciation  indicates  phthisis; 
an  experienced  eye  may  discriminate  between  the  one  and  the  other,  especially  if 
the  discoloration  of  the  face  in  chronic  bronchitis,  or  the  hectic  flush  in  phthisis, 
be  taken  into  account.     The  dusky  flush  of  pneumonia  is  a  very  remarkable  s'vjn 
to  one  who  watches  the  physiognomy  of  disease,  as  is  also  the  peculiar  dragging 
of  the  alas  of  the  nose,  with  hurried  breathing,  noticed  in  pleurisy  or  peritonitis. 
Not  less  distinct  are  the  blue  nose  and  lips  of  disease  of  the  heart. 

The  patient  by  his  attitude  often  unwittingly  reveals  to  the  observant  practi- 
tioner sensations  which  he  fails  to  express  in  words.  A  phthisical  person  rarely 
cares  to  have  his  shoulders  raised  in  bed,  while  one  with  bronchitis  often  does :  in  dis- 
of  the  heart  the  semi-erect  posture,  which  has  suggested  the  name  oforthopncea, 
ost  commonly  selected;  and  even  when  the  lung  symptoms  are  the  most  pro- 
minent, its  presence  pretty  constantly  proves  that  there  must  be  something  more: 
in  some  peculiar  forms  of  disease  a  prone  position  is  the  only  one  iu  which  ease  is 
obtained.  A  patient  with  one  pleura  full  of  fluid  very  generally,  even  when  raised 
in  bed,  inclines  to  the  affected  side,  except  when  pain  prevents  his  doing  so ;  the 
rule  and  the  exception  are  still  more  invariable  when  the  position  is  horizontal. 

Among  the  sensations  of  the  patient,  the  consciousness  of  dyspnoea, — shortness 
of  breath,  felt  especially  in  ascending  a  height  or  going  up  stairs,  has  more  dis- 
tinct reference  to  disease  of  the  heart  than  complaint  of  cough,  which,  when  asso- 
ciated with  expectoration,  more  probably  indicates  affection  of  the  lungs.  Ihe 
principal  facts  to  be  elicited  in  regard  to  pain  are  its  locality,  and  the  circum- 
stances which  attended  its  commencement.  It  may  be  across  the  upper  part  of 
the  thorax  or  at  either  apex;  and  this  is  common  in  phthisis:  sometimes  its  posi- 
tion at  the  lower  part  of  the  chest,  and  the  freedom  of  the  respiration,  prove  it  to 
be  connected  with  the  stomach  or  some  of  the  abdominal  viscera.  On  the  other 
hand,  pain,  distinctly  referred  only  to  one  side,  sharp  and  cutting,  and  situated 
just  below  the  nipple,  always  much  increased,  perhaps  only  felt,  in  the  act  of  cough- 
ing  or  breathing  deeply,  is  very  probably  caused  by  inflammation.  This  point  is 
to  be  considered  with  reference  to  the  coexistence  of  fever,  because  rheumatic  and 
neuralgic  pains  are  similarly  aggravated.  We  have  already  referred  to  the  pain 
of  angina  pectoris  in  discussing  forms  of  neuralgia. 

By  experience  and  observation  much  is  learned  from  the  character  of  the  breath- 
ing, of  the  cough,  and  of  the  expectoration;  aud,  as  aids  to  diagnosis,  they  must 
not  be  omitted;  but  the  student  musj,  be  very  careful  not  to  draw  conclusions  from 
any  of  these  symptoms  alone.  The  prolonged  wheezing  sound,  in  the  act  of  ex- 
piration, by  a  person  labouring  under  emphysema,  is  very  characteristic  in  ex- 
treme cases;  the  cough  is  deficient  in  expiratory  power;  it  seems  a  soft,  forceless 
effort,  with  very  little  vocal  sound,  and  the  voice  cannot  be  elevated  without  diffi- 
culty and  fatigue;  other  conditions,  however,  give  rise  to  characters  very  similar^ 
such  as  pressure  on  the  trachea  or  large  bronchi,  and  even  chronic  dilatation  of 
the  smaller  tubes,  when  obstructed  by  thick,  purulent  secretion. 

The  cough  of  hooping-cough  is  itself  diagnostic,  but  must  not  be  confounded 
with  the  crowing  inspiration  of  childhood,  nor  with  the  harsh,  raucous  sound  of 
croup  or  laryngitis:  by  parents  it  is  sometimes  alleged  to  exist  when  the  child  is 
merely  suffering  from  the  violent  paroxysmal  cough  which  sometimes  attends  ex- 


HISTORY    AND    GENERAL    SYMPTOMS.  191 

tensive  tubercular  deposit,  and  is  not  unfrequently  a  precursor  of  hydrocephalus. 
The  loss  of  voice  in  affections  of  the  larynx,  and  the  noisy  breathing  which  is  au- 
dible at  a  considerable  distance,  when  the  disease  is  accompanied  by  partial  closure 
of  the  glottis  are  almost  unmistakeable. 

The  ringing  cough  of  croup,  once  heard,  can  scarcely  be  forgotten ;  but  false 
diagnosis  has  not  unfrequently  been  made,  from  some  sound  which  has  merely 
simulated  it  being  alone  taken  into  consideration.  The  short  hacking  of  early 
phthisis,  and  the  stifled  and  suppressed  cough  of  its  more  advanced  stages. — the 
rattling  and  straining,  often  ending  in  sickness,  attending  the  emptying  of  a  large 
cavity, — are  all  more  or  less  significant. 

The  absolute  quickness  or  slowness  of  respiration,  and  also  its  ratio  to  the  ra- 
pidity of  the  pulse,  are  rather  to  be  regarded  as  evidence  of  the  severity  of  the  af- 
fection than  as  specially  pointing  out  its  nature:  such,  for  example,  are  the  very 
hurried  breath  of  extensive  tuberculosis,  and  the  want  of  correspondence  between 
its  increased  frequency  and  the  acceleration  of  the  pulse  in  severe  pneumonia.  A 
distinction  is  to  be  made  between  the  evidence  of  quick  breathing  derived  from 
observation  and  the  sensation  of  the  patient  that  it  is  short.  The  character  of  the 
sputa  often  helps  to  correct  our  diagnosis  when  there  is  anything  like  incongruity 
in  the  symptoms  or  physical  signs  of  disease.  The  chief  conditions  which  may 
be  observed  are  these:  simple  mucus,  of  varying  degrees  of  adhesiveness  and 
amount,  in  pleurisy,  catarrh,  bronchial  irritation,  and  bronchorrhoea:  mucilaginous 
or  rice- water  sputa,  seen  in  the  early  stages  of  phthisis;  purulent  mucus  and 
chronic  bronchitis;  unmixed  pus  coming  from  a  cavity;  adhesive  rust-coloured 
mucus,  very  distinctive  of  pneumonia;  admixture  of  blood,  from  slender  streaks 
to  copious  hemorrhage;  and  offensive  discharges.  In  many  instances  these 
varieties  approximate  very  closely  to  each  other;  thus  the  muco-purulent  ex- 
pectoration of  bronchitis  may  assume  the  appearance  of  unmixed  pus.  When 
bronchitis  coexists,  as  it  so  often  does,  with  phthisis,  the  sputa  present  every  de- 
gree of  consistency,  and  the  imperfect  admixture  of  the  secretions  due  to  each 
cause  sometimes  points  out  their  combination.  In  the  earliest  stage  of  phtkisis  it 
is  only  that  of  bronchial  irritation,  and  in  pleurisy  there  is  usually  no  expectora- 
tion beyond  a  little  salivary-looking  fluid;  glairiness  or  adhesiveness,  and  espe- 
cially a  brown  tinge,  prove  that  the  inflammation  is  not  confined  to  the  pleura.  Pu- 
riform  sputa  may  have  most  of  the  characters  of  a  cavity  when  the  pus  comes  not 
from  a  vomica,  but  from  the  cavity  of  the  pleura:  in  such  circumstances,  a  gush 
of  pus,  instantaneously  discharged,  would  indicate  that  the  opening  into  the  pleura 
was  a  consequence  of  empyema  and  not  of  phthisis.  With  reference  to  the  rusty 
sputa  of  pneumonia,  while  the  adhesiveness  is  generally  in  proportion  to  the  se- 
verity of  the  inflammation,  the  student  must  be  careful  to  ascertain  correctly,  in 
cases  where  the  secretion  is  more  abundant,  that  the  colour  is  really  produced  by 
slight  admixture  of  blood,  and  is  not  caused  by  the  colouring  matter  of  wine  or 
medicine. 

The  blood  expectorated  in  phthisis  differs  from  that  of  pneumonia,  not  only  in 
its  brighter  colour,  but  in  its  being  less  perfectly  intermixed  with  the  other  secre- 
tion ;  its  amount  is  exceedingly  indeterminate.  In  a  large  proportion  of  consump- 
tive patients  it  may  be  ascertained  that  hemorrhage  from  the  smallest  to  the 
largest  amount  has  at  one  time  or  other  existed,  and  therefore  the  fact  in  any  in- 
dividual case  is  not  without  value;  but  it  is  true  that  certain  phthisical  patients 
escape  altogether,  that  in  some  cases  it  is  dependent  on  other  causes,  and  that  pa- 
tients often  sedulously  endeavour  to  conceal  or  ignore  it. 

Sometimes  the  expectoration  is  offensive,  and  occasionally  it  is  so  to  a  very  high 
degree.  The  cause  of  this  is  no  doubt  the  admixture  of  disintegrated  lung  tissue; 
but  while  occasionally  the  process  is  rapid  and  gangrenous,  with  black  and  gru- 
mous  sputa,  more  frequently  it  is  merely  fetid  pus,  the  result  of  rapid  and  un- 
healthy suppuration:  both  are  generally  confounded  together  as  gangrene,  but  the 
condition  of  fetid  abscess  ought  to  be  distinguished  from  it. 

In  the  observation  of  all  these  points  it  is  often  necessary  to  wait  until  anything 
like  flurry  or  nervous  excitement  have  passed,  or  at  least  to  correct  the  observa- 
tions made  on  first  seeing  the  patient  by  others  at  the  end  of  the  visit,  and  not 
unfrequently  to  abstract  the  patient's  attention  from  the  particular  symptom  which 
is  for  the  moment  the  subject  of  observation. 


L92  EXAMINATION    OF  THE    CHEST. 

§  '2.  Physical  Signs. — It  is  not  necessary  in  the  present  day  to 
Btudy  much  in  detail  those,  the  general  symptoms  of  disease  of  the 
chesl  :  but  there  was  a  time  when,  to  the  correct  interpretation  of 

Buch  \ : i l: u o  and  uncertain  signs,  the  attention  of  the  physician  was 
confined.  In  our  own  day  diagnosis  has  made  great  advance  in 
consequence  of  the  light  thrown  upon  this  class  of  diseases  by  the 
practice  of  auscultation  and  percussion,  and  the  error  to  which  wc 
arc  liable  is  that  of  overlooking  the  general  symptoms,  and  being 
satisfied  with  the  physical  signs;  and  the  deductions  from  these  two 
sources  of  information,  if  considered  apart,  may  be  wholly  at  va- 
riance with  each  other.  The  student  should  therefore  make  careful 
note  of  all  that  he  can  acquire  of  the  history  and  the  general  indi- 
cations before  he  proceeds  to  the  minute  examination  of  the  organs 
of  circulation  and  respiration,  in  order  that  he  may  correct  the  in- 
ferences he  may  be  disposed  to  draw  from  this  source  by  observa- 
tions made  before  his  judgment  had  received  aDy  bias  from  the  indi- 
cations it  affords. 

The  facts  which  we  have  to  study  consist  of  the  relative  move- 
ments of  the  different  parts  of  the  chest,  the  proportion  and  position 
of  solids  or  fluids  and  air  as  determined  by  percussion,  and  the 
sounds  produced,  whether  normally  or  abnormally,  by  the  movement 
of  air,  or  air  and  fluid  together,  in  the  lungs,  and  of  blood  and 
solid  structures  in  the  heart  and  great  vessels;  and  in  connexion 
with* these,  the  condition  of  parts  as  sound-conducting,  or  sound- 
generating  media.    To  describe  these  sounds  in  such  a  way  as  to  be 
intelligible  to  one  who  has  never  heard  them  is  impossible,  and  to 
describe  them  to  one  who  has,  is  unnecessary.    I  would  only  remark 
that  any  student  who  will  take  the  trouble  of  examining  the  chest 
of  every  patient,  will  learn  to  distinguish  the  sounds  of  health  and 
disease' in  a  very  short  time;  while  those  who  merely  listen  to  such 
cases  as  are  pointed  out  to  them  as  instances  of  certain  diseases,  or 
of  certain  unusual  sounds,  will  never  have  an  adequate  notion  of 
the  value  of  auscultation.     It  is  absolutely  necessary,  in  order  to 
make  any  advance  at  all,  that  the  natural  respiratory  sound,  and 
the   natural   first   and  second  sounds  of  the  heart,  be  known  and 
understood;  and  the  student  who  is  anxious  to  learn  them  will  never 
come  away  satisfied  with  having  heard  nothing^    It  too  often  hap- 
pens with  the   learner,  that  when   some   peculiar  circumstance  is 
pointed  out  to  him  in  the  wards,  he  is  too  hurried  or  too  nervous  to 
catch   the  sound  described:   in   all   such  cases,  my  advice  to  him 
would  be  to  remove  his  ear  to  some  other  part  of  the  chest  where 
he  knows  the  natural  sounds  are  most  easily  to  be  heard,  and  gra- 
dually and  patiently  to  approach  the  point  to  which  his  attention 
was  first  called;  a  sound  once  heard  becomes  louder  and  more  dis- 
tinct, as  it  becomes  more  familiar  to  the  ear  by  prolonged  attention : 
if  he  then  take  the  earliest  opportunity  of  comparing  what  he  has 
just  heard  with  that  which  is  to  be  found  in  the  same  spot  in  a  pa- 
tient not  labouring  under  disease  of  the  chest,  he  will  best  know 


EXTERNAL  APPEARANCES.  19 


n 


whether  he  have  learned  anything  that  may  be  of  value  to  him 
afterwards, 

a.  External  Appearances. — If  we  were  to  follow  strictly  the 
order  in  which  the  various  organs  are  placed  in  the  Table  of  Dis- 
eases, we  should  commence  with  diseases  of  the  heart  and  blood- 
vessels, which  have  been  placed  before  those  of  the  respiratory 
organs,  because  they  have  less  of  a  local  character ;  the  circulatory 
apparatus  being  distributed,  like  the  nerves,  to  every  part  of  the 
body.  With  reference  to  diagnosis,  there  seems  an  advantage  in 
pursuing  a  different  course ;  because  diseases  of  the  heart  are  more 
readily  understood  when  the  phenomena  connected  with  the  lun^s, 
which  occupy  so  much  more  space  in  the  thoracic  cavity,  have  been 
previously  explained. 

In  exploring  the  chest  it  is  essential  to  contrast  the  signs  observed 
in  corresponding  parts  on  each  side,  because  there  can  be  no  abso- 
lute standard  of  comparison  applicable  to  all  cases:  the  differences 
must  be  noted  as  the  examination  proceeds,  but  no  conclusions  ought 
to  be  drawn  from  them  till  the  examination  be  completed.  Regard 
must  first  be  had  to  the  external  symmetry,  and  then  to  the  move- 
ment of  its  various  parts  in  the  act  of  breathing;  and  we  may  at 
the  same  time  observe  whether  the  vocal  fremitus  or  thrill  be  equally 
perceived  by  the  hand  on  either  side  when  the  patient  speaks.  De- 
viations of  form  serve  either  as  indications  of  bygone  disease,  such 
as  the  rachitic  distortion  of  the  ribs  in  childhood,  the  scrofulous 
caries  of  the  spine,  or  the  lateral  curvature  of  imperfect  develop- 
ment; or  as  signs  of  still  existing  changes  in  the  respiratory  organs 
of  some  duration ;  for  example,  the  rounded  chest  of  emphysema, 
or  the  flattened  one  of  phthisis,  or  the  lateral  distention  of  pleural 
effusion.  Alterations  in  movement,  again,  if  we  exclude  the  effects 
of  muscular  paralysis,  and  anchylosis  of  ribs,  have  more  direct 
bearing  on  the  condition  of  the  lungs  with  reference  to  their  power 
of  expansion :  and,  contrary  to  what  might  have  been  expected  in 
so  mobile  an  organ,  the  actual  position  of  the  diseased  portion  is 
often  very  accurately  pointed  out  by  deficient  movement  of  the  ribs 
over  that  particular  part  of  the  lung. 

These  points  are  not  of  very  great  importance  in  diagnosis,  because  of  necessity- 
disease  has  proceeded  to  a  considerable  extent  before  it  becomes  distinctly  mani- 
fested in  the  form  and  movements  of  the  chest.  But  they  serve,  when  present,  to 
give  certain  impressions  which  aid  the  practitioner  in  forming  a  rapid  diagnosis, 
and  therefore  demand  the  attention  of  the  student:  and  they  also  serve  sometimes 
to  correct  an  error  into  which  we  might  inadvertently  fall  if  they  were  overlooked. 
Distortion,  especially  that  produced  by  spinal  curvature,  is  very  liable  to  render 
the  ordinary  physical  signs  fallacious,  and  due  allowance  must  be  made  for  this 
circumstance  in  forming  a  judgment  upon  them.  Among  the  more  important 
points  with  which  the  student  should  make  himself  familiar,  we  may  enumerate 
the  following : — (1 )  The  upper  ribs  sink  away  from  the  clavicle,  become  flattened 
and  motionless  in  advancing  phthisis,  while  in  many  cases  the  movement  of  the 
lower  ones  is  not  interfered  with,  and  as  a  general  rule  the  change  is  more  evident 
on  one  side  than  the  other.  (2)  In  emphysema  the  opposite  condition  prevails- 
the  chest  is  full  and  rounded,  the  ribs  stand  out,  but  have  a  very  slight  ranee  of 


194  EXAMINATION    OF    THE    CHEST. 

movement,  and  the  inspiratory  effort  is  marked  by  powerful  traction  of  the  mus- 
of  the  nick :  the  movement  of  the  lower  part  of  the  chest  la  very  often  intoai  d 
in  place  of  outward  during  inspiration:  the  contrast  between  the  opposite  Bides  is 
seldom   very  great.     ('■>)  When  one  side  only  bulges,  and  the  interci  ices 

obliterated,  ili«'  effect  is  usually  produced  by  distention  of  the  pleura  with  fluid 
or  air.  (1)  Without  any  deviation  in  form,  a  remarkable  stillness  and  want  of 
movement  may  be  observed  in  the  early  stage  of  inflammation  of  the  pleura;  and 
when  the  disease  is  very  limited,  this  effect  maybe  quite  local,  (.">)  A  very 
Striking  change  may  be  noticed  in  the  contraction  of  one  side,  when  there  is  no 
distortion  of  the  spiue,  as  a  consequence  of  previously  existing  empyema,  (6) 
The  contrast  between  thoracic  breathing,  when  the  diaphragm  is  not  moved,  in 
peritonitis,  and  abdominal  breathing  when  all  the  respiratory  nerves,  except  the 
phrenic,  are  paralyzed  by  injury  of  the  upper  part  of  the  spinal  cord,  is  well  worthy 
of  observation;  its  miuor  degrees  ought  also  to  be  considered  iu  diagnosis. 

b.  Percussion. — The  operator  elicits  the  sound  by  his  own  act, 
his  object  being  to  ascertain  the  relative  amount  and  position  of 
the  solid  or  fluid  and  gaseous  contents  of  the  thorax.  The  stroke 
should  be  short  and  sharp,  and  not  more  forcible  than  is  necessary 
to  produce  a  distinct  sound,  except  when  the  character  of  the  reso- 
nance is  doubtful,  and  then  it  may  become  needful  to  compare  the 
sound  produced  by  firmer  percussion  with  that  which  results  from  a 
gentler  tap.  The  finger  used  as  a  pleximeter  to  receive  the  stroke, 
should  be  level,  and,  when  comparing  diiferent  parts,  should  occupy 
as  nearly  as  possible  the  same  position  with  reference  to  the  ribs, 
whether  parallel  or  transverse,  upon  the  bone  or  in  the  interspace. 
The  information  percussion  conveys  is  derived  from  two  sources: 
the  resonance  or  clearness  of  the  sound  produced,  and  the  sense  of 
greater  or  less  resistance  to  the  finger;  and  it  is  to  be  remembered 
that  these  vary,  not  only  with  the  condition  of  the  lung  itself,  but 
also  with  that  of  the  parietes,  being  remarkably  modified  by  the 
elasticity  of  the  ribs.  In  order  to  obtain  trustworthy  results,  it  is 
essential  to  compare  the  sound  produced  at  corresponding  parts  on 
either  side;  and  also  to  contrast  the  difference  between  the  upper 
and  lower,  regions  on  one  side  with  that  on  the  other. 


'£>' 


Percussion  indicates  either  that  there  is  an  excess  of  solid  and  fluid  compared 
with  gaseous  contents  or  the  contrary,  as  the  sound  is  dull  and  dead  and  the  re- 
sistance great,  or  the  sound  clear  and  resonant  and  the  resistance  slight;  and 
these  conditions  maybe  either  beyond  what  is  consistent  with  perfect  health  under 
any  circumstances,  or  merely  different  from  that  of  the  surrounding  parts  or  the 
corresponding  parts  of  the  other  side  of  the  chest.  It  is  quite  true  that  various 
morbid  states  are  associated  with  unusual  sounds  on  percussion,  which  become 
sensible  to  an  experienced  ear;  but,  except  in  the  extremes  of  tympanitic  reso- 
nance and  remarkable  dulness,  they  are  not  such  as  can  be  well  explained  to  the 
student,  because  there  is  no  absolute  standard  from  which  their  variations  can  be 
calculated. 

Percussion  is  not  equally  applicable  over  all  parts  of  the  chest.  (1)  In  front 
its  variations  are  readily  perceived,  but  it  is  only  over  the  upper  third  that  the  in- 
dications are  of  much  value  with  reference  to  the  lungs.  In  the  middle  third  the 
heart  on  the  leftside  prevents  a  correct  comparison  with  the  right;  and  lower 
down,  while  enlargement  of  the  liver  may  be  the  cause  of  dulness  on  the  right 
.  distention  of  the  stomach  with  gas  may  give  rise  to  unusual  resonance  on  the 
Applied  over  the  region  of  the  heart,  it  teaches  us  whether  a  larger  portion 
of  lung-tissue  than  usual  be  displaced  by  disease  of  this  organ,  or,  on  the  contrary, 


AUSCULTATION.  195 

whether  the  lung  have  encroached  on  the  ordinary  space  of  precordial  dulness. 
(!')  At  either  side  the  upward  pressure  of  the  abdominal  viscera  tends  to  invali- 
date any  results  of  percussion  below,  and  those  only  are  trustworthy  which  are  ob- 
tained from  the  region  bordering  on  the  axillae;  and  even  here  stomach  resonance 
in  rare  cases  makes  itself  heard.  (3)  Over  the  back  the  thickness  of  the  walls  of 
the  chest  limits  us  in  very  great  measure  to  the  inner  border  and  lower  angle  of  the 
scapula,  as  it  requires  considerable  tact  to  make  the  difference  perceptible  even  in 
the  supra-spinal  region,  where,  notwithstanding,  it  is  much  more  readily  applica- 
ble than  upon  or  just  below  the  spine  of  the  scapula.  In  a  downward"  and  out- 
ward direction  we  are  met  by  the  same  difficulties,  which  tend  to  invalidate  the 
effects  of  percussion  in  front  and  on  either  side:  for  practical  purposes,  however, 
the  information  derived  from  the  region  on  either  side  of  the  spine,  when  the  sca- 
pulae are  drawn  aside  by  the  arms  being  crossed  in  front,  is  quite  sufficient. 

e.  Auscultation. — In  this  term  -\ve  include  all  the  sounds  produced 
by  the  movement  of  the  air;  whether  in  ordinary  breathing,  in 
forced  inspiration,  in  the  act  of  coughing,  or  in  the  resonance  of 
the  voice.  "We  have  to  observe  the  sound  caused  by  its  simple  mo- 
tion backwards  and  forwards  in  the  air-tubes  and  vesicles,  to  take 
note  of  the  force  with  which  the  voice  formed  at  the  larynx  is 
transmitted  through  the  tissue  of  the  lung,  and  to  listen  for  any- 
thing unusual  or  abnormal,  which  we  may  call  superadded  sounds. 

The  vesicular  murmur,  as  it  is  called,  heard  loudest  and  often 
alone  in  inspiration,  is  that  which  characterizes  healthy  lung:  it  is 
distinguished  from  unhealthy  breath-sounds  of  all  kinds  by  its  great 
softness,  but  in  loudness  and  distinctness,  perhaps,  no  two  chests 
are  exactly  alike.  The  resonance  of  the  voice  also  differs  extremely 
in  different  persons,  and  even  in  different  parts' of  the  same  lung  in 
perfect  health:  in  disease  its  chief  value  is  derived  from  a  want  of 
correspondence  between  those  in  which  its  intensity  is  usually  equal. 
The  characters  of  superadded  sounds  will  be  discussed  in  Chapter 
XIX.  I  may  here  repeat  that  the  most  practical  advice  that  can; 
be  given  to  a  student  in  entering  the  wards  of  a  hospital,  is  to  ex- 
amine the  chest  in  every  case  when  it  can  be  done  without  sufferino- 
to  the  patient:  if  on  first  applying  his  ear  to  the  stethoscope  he 
should  hear  nothing,  he  may  cause  the  patient  to  inspire  deeply,  to 
talk,  or  to  cough,  when  some  sound  will  be  produced;  and  if  that 
sound  be  peculiar,  he  ought  to  listen  to  it  till  it  can  be  recollected 
and  recognised  again,  and  if  possible  he  should  get  some  more  ex- 
perienced auscultator  to  explain  it.  By  this  means,  in  a  wonderfully 
short  time,  he  will  find  himself  quite  competent  to  say  what  is  healthy 
and  what  unhealthy  breathing,  what  is  natural  and  what  superadded 
sound. 

In  the  detailed  treatises  on  auscultation  descriptions  of  all  possible  sounds  are 
given,  and  names  are  too  often  employed  which  have  tended  rather  to  perplex  than 
to  instruct.  The  nomenclature  has  unfortunately  been  derived  from  the  morbid 
condition  with  which  the  sounds  have  been  supposed  to  be  associated ;  and  in 
well-marked  examples,  no  doubt,  the  name  and  the  association  are  correct;  but  as 
it  necessarily  happens  that  such  morbid  states  are  not  separated  from  each  other 
by  any  distinct  line  of  demarkation,  and  that  the  actual  character  of  the  sound 
cannot  be  very  clearly  defined,  it  seems  unwise  to  employ  a  name  which  suggests 
a  theory  of  disease,  while  prosecuting  an  inquiry  which  is  only  ultimately  to  lead. 


]      i  EXAMINATION    OF    THE    CIIKST. 

rv.     It  is  better,  therefore,  to  confine  ourselves  as  much  as  possible 
to  tcnm  which  convey  ideas  of  Bound  rather  than  ideas  of  disease. 

jcultation  is  best  performed  in  front,  by  means  of  the  stethoscope.     Over  the 

the  ear  more  readily  takes  cognizance  of  the  condition  of  extensive  tracts  of 

hi 1 1 _  .  when  applied  directly,  with  only  the  intervention  of  a  fold  of  linen: 

sounds  have  to  pass  through  much  thicker  parietA,  and  therefore  it  is 

unwise  still  further  to  deaden  them  by  the  intervention  of  an  instrument:  when  it 

becomes  important  to  localize  a  sound,  the  stethoscope  may  be  used. 

In  conditions  of  disease  we  meet  with  modifications  of  the  breath  and  voice- 
sounds,  and  with  superadded  sounds.    There  can  be  no  absolute  standard  of  health 
to  which  the  breath  or  voice-sound  can   be  at  all  times  r.  ferred;  and  heme,  as  iu 
percussion,  our  judgment  in  regard  to  them  must  he  in  great  measure  formed  by 
comparison  of  different  parts  of  the  same  chest.     The  student  must  place  no  reli- 
ance on  what   he  may  consider  deviations  from  the  ideal  standard,  but  confine 
himself  to  discovering  a  want  of  consistency  between  the  two  sides,  and  it  will 
often  require  the  exercise  of  his  clearest  judgment,  and  most  correct  reasoning,  to 
deduce  from  this  want  of  consistency  the  exact  nature  of  the  deviation.     It  is  to 
be  observed  that  difference  in  the  intensity  of  the  voice-sound  is  most  liable  to  mis- 
lead, and  is  least  to  be  relied  on  as  indicating  the  condition  of  the  lungs:  differ- 
ence in  the  loudness  and  quality  of  breath-sound  affords  more  direct  and  more 
satisfactory  evidence:  difference  in  the  resonance  on  percussion  is  uumistakeable 
proof  of  different  degrees  of  density  of  the  lung,  if  the  parietes  be  free  from  disease, 
while  superadded  sound  is  of  necessity  connected  with  something  abnormal :  and 
we  have  only  to  determine  what  that  sound  exactly  is,  and  what  physical  elements 
can  give  rise  to  it.     The  combination  of  the  evidence  derived  from  these  sources, 
with  the  history  of  the  case,  and  the  other  symptoms  of  disease,  forms  the  la-is 
upon  which  our  judgment  concerning  the  pathological  condition  of  the  lungs  ought 
to  rest:  it  is  most  important  to  remember  that  no  one  of  these  facts,  taken  singly, 
is  sufficient  to  warrant  any  deduction  regarding  its  nature;  and  that  the  larger  the 
number  of  facts  which  coincide,  the  more  will  this  deduction  partake  of  the  nature 
rtainty. 
The  loudness  of  these  sounds  in  the  same  individual,  at  different  periods,  or  at 
different  parts  of  the  chest,  depends  on  three  circumstances — the  size  and  form  of 
the  spaces  over  which  we  listen,  the  force  with  which  the  air  moves  or  the  voice 
is  produced,  and  the  power  of  conducting  sound  possessed  by  the  superficial  parts. 
We  may  exclude  the  second  of  those,  as  being  iu  great  measure  under  our  con- 
trol, with  this  remark,  that  now  and  then  it  happens  that  over  an  entire  lung  the 
breathing  may  be  unnaturally  loud  in  consequence  of  its  having  a  vicarious  duty 
to  perform  in  supplying  the  defect  of  its  fellow:  the  air  simply  moves  faster  and 
more  freely — its  sound  is  exaggerated,  and  not  otherwise  changed.     In  regard  to 
the  size  and  form  of  the  spaces  over  which  we  listen,  it  must  be  remembered  that 
not  only  are  these  changed  by  disease,  increased  or  diminished  in  size,  but  at  any 
given  spot  we  encounter  vesicles,  small  bronchi,  and  large  bronchi,  at  different 
depths  from  the  surface;  and  that  if  the  breathing  in  the  vesicles  be  stopped,  we 
shall  hear  the  sounds  in  the  larger  spaces  more  or  less  loudly,  according  to  the 
conducting  power  of  the  lung-tissue  and  the  degree  of  noise  the  air  produces  in 
them.     For  example,  consolidation  will  produce  all  of  these  effects  in  varying  de- 
grees: 1st,  it  gives  rise  to  more  or  less  difference  in  percussion  resonance;  2nd, 
it  impedes  or  suppresses  vesicular  breathing;  3rd,  it  increases  the  conducting 
power  of  the  tissue;  -1th,  it  makes  the  large  tubes  more  rigid,  and  the  breath- 
sound  in  them  more  noisy.     Or,  again,  unnatural  spaces  or  cavities,  of  varying 
size,  existing  along  with  more  or  less  of  consolidation,  will  give  rise  to  a  similar 
series  of  phenomena.     On  the  other  hand,  unusual  expansion  of  the  lung,  while 
it  causes  a  stoppage  of  the  vesicular  breathing,  is  attended  with  opposite  effects 
in  increase  of  resonance,  in  diminution  of  the  conducting  power,  and  in  lessening 
the  noise  of  movement  in  the  large  tubes.     Two  further  considerations  must  be 
borne  in  mind  with  relation  to  these  changes  in  the  breath  and  voice-sounds — 
viz.,  that  the  rhythm  and  quality  of  the  breathing  (the  ratio  of  the  inspiration  to 
the  expiration,  and  the  softness  or  harshness  of  tlie  breathing)  vary  with  different 
sizes  and  forms  of  spaces,  and  consequently  become  the  measure  of  their  capa- 


AUSCULTATION.  197 

city;  while,  by  the  power  of  the  voice,  we  are  best  able  to  judge  of  the  quality  of 
the  superficial  structures  as  a  medium  for  conducting  sound,  and  consequently,  of 
their  degree  of  solidity.  By  some  it  has  been  alleged  that  when  the  tubes  or  pa- 
rietes  of  a  cavity  are  more  rigid,  the  air  is  more  easily  thrown  into  sonorous  vi- 
brations, and  that  tli^s  cause  is  more  powerful  in  producing  vocal  resonance  than 
the  sound-conducting  property:  the  conclusion  is  the  same  in  either  case.  Some 
allowance,  however,  is  to  be  made  for  the  size  of  the  space,  as  it  would  appear  to 
have  something  to  do  with  the  intensity  of  the  vocal  vibration  of  the  air. 

Superadded  sounds  have  reference  to  the  presence  of  some  extraneous  matter 
which,  in  consequence  of  the  movement  of  the  air,  or  that  of  the  lung-tissue,  gives 
rise  to  sounds  which  have  no  resemblance  at  all  to  those  produced  by  healthy 
breathing.  They  may  be  cafPsed  by  the  two  surfaces  of  the  pleura  moving  on  each 
other  with  a  rubbing  sound,  or  by  consolidation  of  the  lung  giving  rise  to  crack- 
ling noises  as  it  expands  when  air  enters,  or  by  air  coming  into  contact  with  fluid, 
whether  serous,  purulent,  or  inspissated;  and  the  sound  in  each  of  these  cases  may 
give  very  direct  evidence  of  the  physical  facts  which  combine  for  its  production; 
but  standing  alone,  as  a  symptom  of  disease,  it  would  be  of  comparatively  small 
value  in  determining  the  condition  of  the  patient. 


198 


CIIArTER  XVIII. 

MODIFICATIONS    OF    NORMAL     BREATH    AND    VOICE-SOUNDS,    AND    OF 

PERCUSSION    RESONANCE. 

Div.  I. — The  Clavicular  Region. — §  1.  Breath  and  Voice-sounds 
with  Dubiess  under  one  Clavicle — §  2,  with  Excessive  Resonance 
— §  3,  with  Difference  on  Percussion  slightly  marked — §  4,  with 
no  perceptible  Difference. 

Div.  II. —  The  Posterior  and  Lateral  Regions. — §  1,  Breath  and 
Vuice-sounds,  with  Dulness  on  one  Side — §  2,  with  Excessive 
Resonance — §  3,  ivith  Difference  on  Percussion  slightly  marked 
— §  4,  ivith  no  perceptible  Difference. 

SUMMARY. — §  I,  Condensation  of  Lung-tissue  —  Carnijication — 
Hepatization — Tuberculization — §  2,  Expansion  of  Lung-tissue 
— Empliysema — §  3,  Condition  of  the  Pleura. 

Y\rE  now  proceed  to  consider  the  method  in  -which  auscultation 
and  percussion  are  to  be  applied  in  endeavouring  to  ascertain  the 
physical  condition  of  the  lungs;  and  in  this  chapter  we  shall  con- 
fine our  attention  to  the  modifications  of  breath  and  voice-sounds 
and  percussion  resonance,  comparing  each  with  the  other  as  we  go 
along,  and  leaving  for  the  present  out  of  consideration  any  sounds 
which  may  be  superadded.  It  is  true  that  in  practice  we  shall  not 
often  find  them  so  disjoined,  but  in  order  to  arrive  at  logical  con- 
clusions from  the  premises  submitted  to  us,  it  is  absolutely  necessary 
to  compare  the  two  simpler  classes  of  phenomena  together  before 
taking  into  account  the  third  and  more  complex  series:  it  will  also 
have  the  advantage  of  preventing  the  student  from  acquiring  the 
pernicious  habit  of  trusting  to  any  sign  as  pathognomonic  of  a  certain 
form  of  disease, — an  error  which  superadded  sound  is  much  more 
liable  to  produce  than  mere  modifications  of  natural  sounds. 

Division  I. — The  Clavicular  Region. 

The  evidence  derived  from  this  region  is  by  far  the  most  valuable 
portion  of  that  which  serves  to  indicate  disease  of  the  upper  lobe: 
changes  of  structure  seldom  exist  on  its  posterior  aspect  of  sufficient 
amount  to  give  rise  to  distinct  auscultatory  phenomena  through  the 
scapula,  without  also  causing  perceptible  change  in  front:  corrobo- 
rative signs  arc  generally  found  behind,  and,  possibly,  disease  which 
seems  of  small  extent  when  we  examine  in  front,  is  far  advanced  in 
the  scapular  region.  Still  the  first  and  the  most  correct  knowledge 
of  its  existence  usually  comes  from  the  clavicular  region,  and  it  is 
a  good  rule  that  it  should  be  the  first  examined. 


AUSCULTATION   AND    PERCUSSION.  199 

§  1.  Percussion  notes  a  marked  difference  between  the  two  sides 
of  the  chest,  and  one  has  a  dull,  dead  resonance,  with  a  sense  of 
resistance. 

A.  The  breathing  is  louder  on  the  duller  side;  there  is  a  very 
evident  prolongation  of  the  expiratory  murmur;  it  has  acquired  an 
unnatural  harshness  and  a  blowing  sound:  the  voice-sound  is  also 
louder,  and  probably  changed  in  character  as  compared  with  the 
other  side  of  the  chest.  There  can  be  no  doubt  that  the  disease  is 
on  the  duller  side,  and  of  some  form  associated  with  consolidation. 
In  this  region  we  meet  with  tubercular  deposit,  fibrinous  deposit, 
and  retraction  of  the  lung  consequent  on  effusion  into  the  cavity 
of  the  pleura. 

B.  .The  breathing  is  weaker  on  the  duller  side. 

a.  It  is  entirely  superseded  by  superadded  sound:  the  voice- 
sound  is  loud  and  harsh ;  the  sound  of  the  breathing  is  manifestly 
obstructed  by  some  extraneous  fluid  mixed  with  the  air  contained 
in  the  lung,  and  in  addition  to  this  we  feel  sure,  from  the  deadness 
of  the  percussion-stroke  and  the  loudness  of  the  voice,  that  there  is 
some  form  of  consolidation  present,  generally  the  tubercular.  (See 
next  Chapter,  Div.  I.,  §  1,  a.) 

b.  The  dulness  and  deadness  of  the  percussion-stroke  are  most 
complete,  and  are  evidently  not  confined  to  the  clavicular  region,  but 
extend  throughout  every  part  of  the  chest  on  the  affected  side ;  the 
rhythm  of  the  breathing,  if  any  can  be  heard  at  all,  is  altered  by 
disproportionate  length  of  the  expiration,  and  the  voice-sound  has 
a  loud  ringing  character.  The  chest  is  probably  full  of  fluid  on 
that  side,  but  the  existence  of  this  condition  is  to  be  decided  from 
a  consideration  of  the  signs  appertaining  to  the  remainder  of  the 
chest. 

c.  The  sound  on  percussion  varies  according  to  the  force  of  the 
stroke:  a  gentle  tap  brings  out  imperfect  superficial  resonance,  a 
firmer  stroke  distinct  and  decided  dulness;  the  breathing  is  weak 
and  not  otherwise  altered  in  rhythm  or  quality,  but  in  addition  to 
the  vesicular  murmur  there  may  be  heard  a  sound  of  distant  blow- 
ing. This  would  point  out  some  solid  mass  occupying  a  central 
position  with  reference  to  the  lung. 

d.  There  is  local  swelling  under  the  clavicle,  and  the  breathing  is 
entirely  suppressed.  Here  we  have  no  doubt  of  the  existence  of 
tumour,  aneurism,  or  solid  growth,  as  the  case  may  be. 

§  2.  Percussion  notes  a  remarkable  difference  with  exaggeration 
of  resonance  on  one  side  of  the  chest. 

A.  The  breathing  is  louder  on  the  more  resonant  side. 

a.  The  percussion  sound  is  tympanitic,  while  there  is  a  sensation 
of  wooden  resistance  to  the  stroke:  the  breath-sound  is  heard  as  if 
one  were  blowing  into  a  large  empty  jar;  the  voice-sOund  has  the 
same  character,  called  amphoric.  These  signs  may  be  caused  either 
by  air  in  the  pleura  (pneumo-thorax,)  with  an  opening  communi- 


200  AUSCULTATION    AND    PERCUSSION. 

eating  between  the  lung  and  the  pleural  sac.  somewhere  near  the 
clavicle,  or  by  a  cavity  of  very  large  size:  in  the  one  case  the  tym- 
panitic resonance  is  general,  in  the  other  local. 

b.  The  percussion-sound  is  less  distinctly  tympanitic,  and  there 
is  no  resistance;  the  breath-sound  has  a  blowing  character;  the 
voice-sound  is  ringing.  This  condition  is  often  met  with  in  the  first 
stage  of  pleuritic  effusion:  its  true  nature  is  only  revealed  by  ex- 
ploring the  remainder  of  the  chest. 

B.  The  breathing  is  weaker  on  the  mpre  resonant  side,  or  absent. 

a.  The  resonance  is  not  tympanitic,  but  is  remarkably  clear,  with 
great  elasticity:  if  any  breathing  be  audible,  it  generally  consists 
of  a  long,  distant,  blowing,  expiratory  sound;  there  is  no  voice- 
sound.  Here  Ave  have  decidedly  emphysema  of  the  upper  lobe  of  the 
affected  side. 

b.  The  resonance  is  tympanitic,  and  at  the  same  time  clear;  the 
breath-sound  is  simply  weak  and  distant,  its  rhythm  not  necessarily 
altered;  the  voice-sound  varies.  Such  is  the  effect  produced  by  a 
small  portion  of  air  confined  in  the  pleura:  a  rare  circumstance, 
which  sometimes  follows  on  paracentesis,  and  has  even  been  alleged 
to  be  the  result  of  spontaneous  development. 

c.  In  some  cases  of  pneumo-thorax,  while  the  percussion  resonance 
is  tympanitic  with  a  wooden  tone,  the  amphoric  breath  and  voice- 
sounds  are  not  heard,  or  only  heard  at  a  distance;  either  because 
the  opening  is  temporarily  closed,  or  is  situated  at  some  other  part 
of  the  lung :  these  cases  can  only  be  rightly  judged  of  by  compari- 
son with  the  remainder  of  the  chest. 

§  3.  There  is  little  difference  on  percussion,  and  no  resistance  on 
either  side. 

a.  The  breathing  is  loudest  on  the  duller  side. 

a.  Its  rhythm  is  altered,  the  expiratory  sound  is  especially  pro- 
longed, loud,  and  harsh ;  the  voice-sound  is  also  louder  than  on  the 
more  resonant  side,  which  seems  to  approximate  to  the  healthy 
standard.  We  have  here  a  less  marked  form  of  consolidation; 
most  probably,  from  its  situation,  tubercular,  but  possibly  due  to 
other  causes. 

I.  Its  rhythm  is  natural.  On  the  opposite  side  the  inspiratory 
sound  is  deficient,  and  the  expiratory  sound  is  prolonged,  but  with- 
out any  degree  of  harshness,  any  change  in  quality  being  rather 
indicated  by  softness  and  weakness:  the  voice-sound  is  louder  on 
the  duller  side,  but  not  remarkably  so,  while  on  the  other  it  is  weak 
or  almost  absent.  This  is  sufficient  to  prove  that  the  disease  is  on 
the  more  resonant  side,  and  that  the  condition  is  one  of  dilatation. 

b.  The  breathing  is  weakest  on  the  duller  side.  Its  rhythm  is 
altered,  it  has  a  wavy  or  jerking  character,  and  the  expiration  is 
prolonged:  the  voice-sound,  in  contrast  to  the  preceding  case,  comes 
out  much  more  loudly  on  that  side  on  which  the  breathing  is  defi- 
cient.    The  condition  is  one  of  commencing  consolidation. 


THE   CLAVICULAR   REGION.  201 

§  4.  Percussion  fails  in  detecting  any  difference  between  the  two 
sides  of  the  chest. 

a.  Both  lungs  may  be  in  their  natural  condition  at  this  part:  the 
ratio  of  the  inspiration  and  expiration  corresponds  on  either  side, 
as  well  as  the  loudness  of  the  voice-sound,  and  all  comes  within  the 
limits  of  health. 

B.  The  resonance  on  both  sides  may  be  exaggerated ;  the  chest 
remarkably  rounded  and  resilient,  and  moving  very  little  in  respi- 
ration; the  upper  ribs  not  descending  as  far  as  they  ought  in  expi- 
ration, while  in  inspiration  the  lower  ribs  are  usually  drawn 
inwards:  the  inspiratory  sound  is  short  and  deficient,  and  the  expi- 
ratory prolonged  and  distant;  the  voice-sound  more  or  less  abo- 
lished, as  the  disease  affects  chiefly  the  upper  or  lower  part  of  the 
lung.  Such  are  the  physical  characters  of  emphysema  affecting 
both  lungs. 

c.  Both  sides  may  be  duller  on  percussion  than  in  health. 

a.  The  deficient  resonance  may  depend  upon  loss  of  elasticity  of 
the  ribs,  and  the  breathing  may  still  be  natural  and  equal  on  both 
sides,  or  it  may  have  undergone  some  modification  and  be  accompa- 
nied by  superadded  sounds.  The  probability  of  such  an  explana- 
tion being  correct  must  be  judged  of  by  the  age  of  the  patient; 
the  exact  condition  of  the  lung  can  only  be  determined  by  the  na- 
ture of  the  superadded  sounds. 

b.  The  dulness  may  be  caused  by  consolidation,  and  the  charac- 
ters of  the  breath  and  voice-sounds  are  necessarily  changed.  When 
the  disease  is  so  decided  that  the  dulness  is  quite  unquestionable, 
I  believe  it  is  never  equal  on  both  sides :  the  case  really  fails  under 
§  1,  and  other  morbid  sounds  rarely  fail  to  give  indications  of  dis- 
ease: when  the  dulness  is  slight,  the  principles  of  diagnosis  are 
the  same  as  in  the  next  subdivision. 

D.  A  slight  difference  may  exist,  but  the  ear  may  fail  to  detect 
it.  On  comparison  of  corresponding  portions  of  the  two  lungs, 
somewhere  or  other  a  difference  in  rhythm  or  quality  of  breath- 
sound  and  in  the  intensity  of  the  voice-sound  is  distinguished  by 
auscultation ;  and  we  will  suppose  that  no  corresponding  changes 
are  discovered  in  an  examination  of  the  rest  of  the  chest.  Fortu- 
nately there  is  very  generally  some  superadded  sound  to  guide  our 
determination ;  but  when  absent  we  have  to  decide  what  circum- 
stances justify  us  in  assuming  the  existence  of  disease  in  the  upper 
lobes.  The  question  is  a  weighty  one,  because  here  it  is  that  tuber- 
cle is  generally  first  deposited;  but  we  must  not  forget  that  general 
symptoms  indicating  the  possibility  ought  to  be  present  to  justify 
the  assumption.  Reverting  to  §  3,  and  imagining  the  difference  on 
percussion  to  be  so  slight  as  to  be  overlooked,  we  find  that  there 
may  be  local  emphysema  or  consolidation,  and  that  in  either  case 
the  expiration  may  be  prolonged,  but  that  the  inspiration  in  emphy- 
sema tends  to  softness,  in  consolidation  to  harshness ;  further,  that 
if  the  voice-sound  differ,  it  is  weaker  with  the  prolonged  expiration 


202  AUSCULTATION    AND    PERCUSSION. 

of  emphysema,  louder  with  the  prolonged  expiration  of  consolida- 
tion, than  at  the  corresponding  portion  of  the  opposite  lung.  One 
important  fact  simplifies  the  inquiry  very  much:  it  is  this,  that  if 
there  be  no  superadded  sound  in  emphysema,  we  shall  have  little 
or  no  cough,  and  no  general  symptoms:  we  have  therefore  only  to 
decide  what  difference  in  the  results  of  auscultation  is  sufficient  to 
determine  that  the  general  symptoms  are  due  to  commencing  con- 
solidation. (1)  The  most  certain  indication  is  when  on  one  side  the 
inspiration  is  shorter  and  the  expiration  longer  than  on  the  other. 
(2)  The  next  in  order  of  distinctness  is  when  the  inspiratory  sound 
is  wavy  or  jerking  in  place  of  heing  even  and  continuous.  (3) 
'When  both  sounds  are  longer  and  louder  on  one  side,  the  indication 
is  only  trustworthy  if  they  be  also  harsh  and  unnatural  there,  while 
on  the  other  side  they  continue  soft;  or,  when  this  exaggeration  is 
confined  to  the  left  side,  for  on  the  right  side  they  are  often  louder 
in  perfect  health.  (4)  The  expiration  heard  only  on  one  side  with 
no  other  change  is  a  suspicious  sign.  (5)  The  inspiration  heard 
louder  on  the  left  side  is  also  suspicious.  (6)  The  voice-sound 
heard  louder  on  the  left  side  along  with  any  of  these  changes  is  a 
much  stronger  confirmation  than  when  heard  louder  on  the  right. 

When  a  difference  is  established  by  percussion,  it  is  evident  that  the  lungs  are 
in  different  states,  and  yet  neither  may  be  absolutely  healthy;  the  same  condition 
may  have  commenced  in  one  which  is  advanced  in  the  other.  Considerable  ex- 
perience may  bo  requisite  to  justify  the  assertion  that  both  are  diseased,  but  the 
conclusion  may  be  a  correct  one,  -with  very  imperfect  knowledge,  in  the  cases  re- 
ferred to  in  §  1,  that  there  is  consolidation  on  the  duller  side.  The  dulness  is  ab- 
solute as  well  as  relative;  the  breath-sound  is  changed  in  rhythm  and  quality  at 
the  same  time  that  it  is  louder,  and  the  voice-sound  points  to  the  same  conclusion. 

But  let  us  be  very  careful  how  we  take  the  next  step  and  determine  what  that 
consolidation  is.  ft  is  of  the  utmost  importance  to  leave  the  mind  as  much -un- 
biassed as  possible  by  the  facts  elicited  by  percussion  and  auscultation  in  the  cla- 
vicular region,  because  the  conclusion  must  rest  quite  as  much  upon  the  history 
of  the  pase,  and  upon  the  evidence  derived  from  other  regions  of  the  chest:  and 
till  these  are  compared  together  we  are  not  in  a  position  to  form  any  opinion  whe- 
ther the  cause  of  consolidation  be  tubercles,  pneumonia,  or  pleurisy. 

No  distinction  has  been  here  made  between  the  varieties  of  blowing  sounds, 
whether  diffuse  or  tubular,  bronchial  or  cavernous.  In  so  far  as  these  names  ex- 
press conditions  of  lung  they  are  objectionable,  and  in  so  far  as  they  express  dif- 
ferences of  sound  they  may  be  of  value  to  us  afterwards  in  deciding  what  is  the 
actual  cause  of  the  consolidation;  but  at  present  it  is  quite  immaterial  to  our  in- 
quiry wlnther  the  sound  be  formed  in  a  large  bronchus  or  in  a  vomica.  The  dif- 
ference is  one  of  degree,  not  of  kind,  and  the  fact  is  simply  that  a  blowing  sound 
is  heard  on  that  side  which  is  dull  on  percussion,  and  we  determine  that  these  two 
circumstances  taken  together  prove  the  existence  of  consolidation. 

]>ulness  on  percussion  would  seem  to  be  opposed  to  the  idea  of  the  lung  being 
hollowed  out  by  cavities;  and  the  conclusion  would  appear  to  be  not  unnatural, 
that  whin  the  breathing  is  louder  from  this  cause,  the  resonance  on  pereus 
ought  to  be  greater  than  on  the  opposite  side.     Such  a  condition  certainly  does 
occur  in  the  ce  of  a  large  superficial  cavity,  when  the  percussion  sound  pre- 

sents a  wooden  hollowness  (of  this  kind  is  the  cracked-pot  sound:)  and  an  expert 
auscultator  can  by  percussion  alone  feel  pretty  certain  regarding  the  causes  of  such 
differences:  1 1 1 . -  Btudenl  must  be  content  a1  first  with  the  broad  distinctions  of  in- 
crea  sea"  ami  diminished  resonance  ami  resistance.  The  long  blowing  breath-sound 
heard  with  a  tumour  on  one  side  of  the  chest,  is  to  be  accounted  for  by  its  press- 


TI1E    CLAVICULAR    REGION.  203 

ing  on  some  large  bronchus:  on  careful  auscultation  it  will  be  noticed  that  this 
sound  is  heard  in  addition  to,  not  instead  of,  the  vesicular  breathing;  the  latter, 
however,  is  weaker  than  on  the  healthy  side. 

When  remarkable  resonance  is  heard,  as  referred  to  in  \  2,  it  is  to  be  noted  first 
whether  this  be  general  or  local ;  and  next  whether  the  sound  represent  merely  a 
great  exaggeration  of  the  natural  sound  with  complete  resiliency,  or  have  acquired 
any  peculiar  or  tympanitic  tone,  and  whether  it  be  accompanied  by  a  sense  of  re- 
sistance: the  examination  of  the  posterior  part  of  the  chest  will  readily  clear  up 
any  doubt  between  a  large  cavity  and  a  condition  of  pneumo-thorax  :  it  will  equally 
answer  the  question  as  to  the  presence  of  fluid  in  the  pleura  and  of  emphysema 
in  the  marked  form  to  which  this  section  refers  :  the  possible  contingency  of  a  small 
portion  of  air  occupying  the  upper  part  of  the  pleura  is  best  solved  by  the  history 
of  the  case.  It  is  very  rarely  met  with  except  after  the  operation  of  paracentesis; 
but  it  probably  does  sometimes  occur  from  spontaneous  decomposition  of  the 
purulent  fluid  of  empyema. 

The  cases  ranged  under  \  3  are  those  most  likely  to  be  confounded  together  by  a 
learner:  his  ear  is  sufficiently  educated  to  know  that  there  is  a  difference  on  per- 
cussion, but  he  may  mistake  the  sharpness  of  the  tone  of  slight  consolidation  for 
an  increase  of  resonance.  It  is  a  good  plan  to  compare  not  only  the  opposite 
sides  of  the  chest,  but  also  the  upper  and  lower  parts  on  the  same  side,  when  it 
will  at  once  be  perceived  that  there  is  a  greater  difference  between  the  resonance 
above  and  below  on  the  duller  side  than  on  the  more  resonant  one;  for  this  indi- 
cation to  be  conclusive,  the  chest  must  be  symmetrical.  Still,  the  fact  does  not 
determine  which  lung  is  the  seat  of  disease,  and  the  first  impression  is  very  pro- 
bably that  it  must  be  on  the  duller  side,  when  in  reality  it  is  perhaps  on  the  more 
resonant  one.  The  safest  course  to  pursue  in  all  possible  cases  of  doubt  is  to  com- 
pare the  whole  auscultatory  phenomena,  not  only  as  heard  at  corresponding  por- 
tions of  opposite  lungs,  but  as  heard  in  different  parts  of  the  same  one:  we  may 
conclude  with  pretty  great  certainty  that  if  under  either  clavicle  they  deviate  much 
from  their  general  character  throughout  the  rest  of  the  chest,  there  disease  of  some 
sort  exists:  and  whether  that  be  of  the  form  of  consolidation  or  of  dilatation  is  to 
be  resolved  by  the  fact  that  comparative  dulness  and  increased  voice-sound  (which 
always  to  a  certain  extent  go  together)  are  found  on  the  healthy  side  when  the 
disease  is  emphysema,  on  the  diseased  side  when  it  is  tubercular.  The  presence 
of  a  dilated  bronchus  in  the  emphysematous  lung,  causing  blowing  breath-sound, 
cannot  so  readily  mislead  us  in  this  as  in  the  following  section,  where  the  result 
of  percussion  is  negative:  in  this  case  the  absence  of  dulness  or  want  of  resili- 
ency should  be  sufficient  to  guard  against  error. 

There  is  one  source  of  fallacy  which  must  be  avoided.  When  emphysema  ex- 
ists to  a  considerable  extent  throughout  the  chest,  and  has  been  accompanied  by 
repeated  attacks  of  bronchitis,  it  frequently  happens  that  all  the  tubes  are  to  a 
certain  extent  rigid  and  dilated.  Now,  if  the  emphysema  be  chiefly  of  the  lower 
lobes,  and  one  of  the  upper  lobes  be  less  affected  than  the  other,  the  breathing 
may  be  almost  entirely  suspended  throughout  the  chest,  while  the  dilated  bronchi 
of  the  least  diseased  structure  give  rise  to  sounds  under  one  clavicle  which  have 
the  character  of  being  produced  in  larger  spaces,  and  not  in  the  vesicles;  and  on 
this  side  there  is  by  comparison  dulness  on  percussion.  How  do  we  know  that 
this  is  not  a  case  of  consolidation?  Simply  by  considering  the  condition  of  the 
rest  of  the  lung:  we  may  be  tolerably  certain  that,  in  extensive  emphysema,  the 
existence  of  tubercular  or  other  consolidation  is  not  to  be  looked  for. 

The  cases  comprised  under  \  4  demand  a  little  more  consideration,  because  the 
information  derived  from  percussion  is  unsatisfactory;  and  the  last  series  repre- 
sents a  most  important  class  of  cases, — early  phthisis,  in  which  no  information 
can  be  obtained  from  the  rest  of  the  chest;  superadded  sounds,  too,  are  often 
wanting;  and  unless  we  can  establish  a  distinct  relation  between  general  symp- 
toms and  auscultatory  phenomena,  our  judgment  must  be  held  in  suspense. 

In  health  there  is  no  great  difference  in  the  intensity  of  the  breath  and  voice- 
sounds  under  each  clavicle  in  the  same  individual;  except  that  they  are  very 
slightly  more  intense  on  the  right  side  than  on  the  left.  Scarcely  any  two  indi- 
viduals present  sounds  exactly  alike,  and  what  would  be  the  effect  of  disease  were 


20-4  AUSCULTATION    AND    PERCUSSION. 

it   heard   in  one.  is  the  normal   condition  in  another.     Bat  though  these  limits  of 

Mi  have  a  very  wide  range,  they  have  r  to  a  certain  standard  with 

Which  the  Btudent  cannot  too   early  make   himself  thoroughly  familial-;  and  when 

in  any  particular  ease  he  finds  the  clavicular  region  on  each  Bide  alike  deviating 
from  it,  he  must  institute  a  comparison  with  the  other  parts  of  the  chest, 

A  patient  does  not  generally  seek  for  relief  from  symptoms  of  emphys  ie; 

it  is  a  permanent  condition  of  ill  health  which  has  been  the  growth  of  years,  ami 
lias   Keen  increased  by  every  cold;  and  it  is  only  when  bronchitis  is  Buperad 
that  he  thinks  of  asking  for  medical  advice.     The  sounds  of  bronchitis  are  I 
lizard  in  addition,  and  hence  it  often  happens  with  inexperienced  auscultators  that 
the  mingled  sounds  of  the  mixed  diseases  are  taken  as  those  of  emphysema  itself, 
and  tin-  possibility  of  emphysema  without  bronchitis  is  forgotten. 

When  partial  dulness  exists  on  both  sides,  from  mere  loss  of  resiliency  of  the 
ribs  the  main  source  of  error  is  the  existence  of  a  dilated  bronchus.  An  elderly 
person  who  has  long  suffered  from  chronic  bronchitis  presents  very  often  rather  a 
flattened  chest;  the  loss  of  elasticity  in  the  ribs  causes  resistance  in  percussion, 
and  tends  to  give  the  stroke  a  dull  sound;  the  large  tubes  become  thickened  and 
dilated,  with  loss  of  elasticity;  the  vesicles  do  not  expand  and  contract  with  their 
usual  freedom,  may  be  closed  by  thickened  mucous  membrane,  or,  when  super- 
added sounds  are  present,  by  inspissated  mucus:  under  such  circumstances,  just 
as  happens  in  emphysema,  blowing  breath-sound  both  with  inspiration  and  expi- 
ration may  be  present,  with  locally  increased  voice-sound ;  and  inasmuch  as  the 
alteration  in  condition  aud  especially  in  form  of  these  tubes  is  unequal,  the  changes 
detected  by  auscultation  are  also  unequal.  When,  in  addition  to  this,  the  signs 
of  general  bronchitis  are  present,  it  becomes  almost  impossible  to  determine  whe- 
ther at  the  apex  there  may  not  be  either  tubercular  consolidation  or  a  number  of 
small  cavities,  or  whether  there  be  only  dilated  bronchial  tubes;  and  the  final  de- 
cision must  rest  more  on  correlative  signs  and  symptoms  than  on  those  of  percus- 
sion and  auscultation  ;  and  we  shall  have  not  unfrequently  to  wait  till  the  general 
bronchitis  be  gone,  before  pronouncing  a  decided  opinion.  Should  the  case  then 
be  submitted  to  a  fresh  examination,  and  nothing  remain  but  the  ill-defined  dul- 
ness on  percussion,  and  a  diffuse  blowing-sound  of  expiration,  nearly  equal  on 
both  sides,  without  the  local  distinctness  of  amphoric  breath  and  voice-sounds,  we 
may  conclude  with  great  confidence  that  there  never  has  been  any  tubercle. 

It  rarely  happens  that  consolidation  is  equally  advanced  in  both  lungs,  and  an 
expert  auscultator  can  geuerally  detect  a  difference  in  sbade  between  the  dulness 
of  the  two  sides;  but  1  must  confess  that  I  have  seen  serious  mistakes  made  in 
attempting  to  determine  by  percussion  alone  which  of  the  two  was  the  most  solidi- 
fied lung. 

Prom  the  advanced  stage  in  which  the  dulness  on  percussion  is  unquestionable, 
it  gradually  passes,  in  cases  of  tubercular  deposit,  into  that  in  which  percussion 
fiiils  in  detecting  consolidation  at  all:  our  means  of  appreciation  are  not  sufficiently 
accurate,  and  the  two  sides  of  the  chest  are  not  even  in  health  shaped  exactly 
alike:  while  the  difficulty  of  course  is  increased  when  the  deposit  is  deep-seated 
and  healthy  or  nearly  healthy  structure  intervenes  between  it  and  the  parietes.  But 
when  auscultation  is  taken  along  with  percussion,  the  difference  between  the  two 
sides  becomes  more  apparent,  and  the  existence  of  morbid  structure  is  proved  by 
the  changes  in  rhythm  and  quality  of  breathing  and  loudness  of  voice,  as  well  as 
by  the  superadded  sounds,  which  not  only  differ  from  what  is  heard  in  the  rest  of 
the  chest,  but  are  also  unequal  on  its  opposite  sides.  The  expiration  is  ah. 
more  audible  and  somewhat  prolonged,  while  the  inspiration  is  .sometimes  loud  and 
harsh,  sometimes  weak  and  defective;  the  exaggerated  voice-sound,  in  the  latter 
instance,  forming  a  most  striking  and  trustworthy  contrast. 

Assuming  that  a  difference  on  percussion  is  not  clearly  made  out,  superadded 
id  may  at  once  determine  that  local  change  of  some  sort  has  passed  upon  one 
lung;  but  in  its  absence,  or  for  further  confirmation  of  its  cause  when  present,  we 
pare  carefully  by  auscultation  correspnding  portions  of  either  lung.  Jt  may 
happen  that  on  one  side  the  breathing  is  stopped  by  a  plug  of  mucus  in  one  of 
the  tubes:  this  may  be  removed  by  causing  the  patient  to  cough  and  dislodge  the 
obstruction.     In  doubtful  cases  the  act  of  coughing  is  of  use  in  other  ways,  by 


THE     CLAVICULAR    REGION.  205 

changing  the  character  of  superadded  sounds,  and  also  by  causing  the  patient  to 
take  a  deeper  inspiration  than  we  can  get  him  to  do  by  ordinary  means. 

Such  a  slight  condition  of  emphysema  as  may  possibly  exist  with  no  relative 
difference  in  percussion  resonance,  is  of  no  practical  value,  except  as  it  modifies 
the  superadded  sounds  of  bronchitis  when  any  such  are  present ;  our  chief  concern 
is  to  be  able  to  detect  with  some  degree  of  certainty  the  early  deposit  of  tubercle. 
Rational  diagnosis  alike  seeks  to  avoid  forming  hasty  conclusions  from  insufficient 
premises,  and  neglecting  evidences  which,  however  slight,  are  of  real  import;  and 
with  this  view  the  indications  of  early  deposit  have  been  ranged  in  the  last  sub- 
division of  this  section  pretty  nearly  in  the  order  of  their  importance.  It  is  to  be 
remembered  that  alteration  of  rhythm,  or  quality  of  breath-sound,  is  much  more  im- 
portant than  mere  loudness  or  distinctness,  ami  that  naturally  both  the  breathing 
and  the  voice  are  louder  on  the  right  side  of  the  chest  than  the  left. 

A  word  must  be  said  of  other  phenomena  as  evidence  of  consolidation,  which 
are  derived,  not  from  the  lungs  themselves,  but  from  the  sounds  produced  in  the 
heart  and  arteries,  which  are  transmitted  through  the  lung.  When  the  heart- 
sounds  are  heard  more  loudly  at  the  right  apex  than  at  the  left,  or  a  blowing 
arterial  murmur  is  heard  in  the  subclavian  artery,  generally  on  the  left  side, 
there  is  reason  to  suspect  consolidation;  but  both  are  unquestionably  only  of 
value  as  confirmatory  of  other  signs. 

Such  is  a  general  outline  of  the  evidence  as  to  the  condition  of 
the  lungs  derived  from  the  combination  of  percussion  resonance 
and  alterations  in  the  breath  and  voice-sounds  in  the  clavicular  re- 
gion.    Many  of  the  more  obscure  points  require  for  their  elucida- 
tion  an   examination  of  the  other  parts   of  the  chest,  and  in  all 
cases  a  diagnosis  must  neVer  be  attempted  without  making  it :  the 
superadded  sounds  have  yet  to  be  considered,  and  my  object  has 
been  to  place  the  changes  already  spoken  of  in  such  a  simple  point 
of  view  as  to  lead  the  student  by  logical  analysis  to  form  for  him- 
self a  correct  opinion  of  the  state  of  the  patient.     For  this  reason 
many  of  the  more  delicate  modifications  which  find  place  in  elabo- 
rate works  on  auscultation  and    percussion  have  been  purposely 
omitted:  to  a  practised  ear  such  varieties  may  all  be  sufficiently 
intelligible,  as  indicating  peculiar  conditions  of  the  subjacent   tis- 
sue ;  to  the   student   they  are   only  productive  of  confusion.     Let 
us  never  for  a  moment  forget,  that  these  investigations  as  aids  to 
diagnosis  ought  not  to  serve  as  an  opportunity  for  a  parade  of  skill 
on  the  part  of  the  observer,  but  are  to  be  instituted  solely  for  the 
better  determining  the   form  of  disease  under  which  the  patient 
labours.     At  the  same  time  the  student  ought  not  to  be  deterred 
from    making  himself  acquainted  with   all   the  more  complex  phe- 
nomena of  auscultation;  for  in  this,  as  in  all  other  branches  of 
knowledge,  the  man  who  is  most  familiar  with  the  more  abtsruse 
facts  will  most  readily  appreciate  the  simpler  ones ;  and  the  evils 
that  have  resulted   from    paying  too  great  attention  to  physical 
diagnosis   have  arisen   quite  as  much  from  imperfect  knowledge  of 
the  facts  it  discloses,  as  from  disregard  to  symptoms  derived  from 
other  sources.     In  the  exercise  of  a  sound  judgment,  and  with  the 
view  simply  of  ascertaining  the  condition  of  disease,  and  its  most 
appropriate  treatment,  a  practised  ear  will  be  of  essential  service: 
in  following  the  paltry  object  of  a  display  of  skill  in  determining 


20G  AT  SGULTATIOH    AND   PERCUSSION. 

the  exact  condition  of  an  obscure  case,  the  most  dexterous  is  con- 
stantly misled:  1  would  even  add  that  the  self-satisfying  curiosity 
which  seeks  to  investigate  all  the  morbid  phenomena. with  reference 
only  to  post-mortem  appearances  is  a  less  estimable  quality  than 
that  which,  while  satisfied  with  a  more  limited  knowledge,  has  its 
sole  aim  in  alleviating  suffering  and  curing  disease. 

Division  II. — Tiie  Posterior  and  Lateral  Regions  of 

the  Chest. 

In  comparing  together  the  amount  of  percussion  resonance  and 
the  modification  of  breath  and  voice-sounds,  we  find  ourselves  much 
limited  by  the  various  circumstances  already  mentioned  as  inter- 
fering with  the  application  of  percussion  at  the  lower  portions  of  the 
chest,  and  the  indistinctness  of  its  results  upon  the  scapula ;  but  here 
we  have  fortunately  to  deal  less  with  disease  of  small  amount  and 
limited  extent,  more  with  general  conditions  of  whole  lobes  or  the 
entire  side  of  the  chest.  The  breathing  differs  in  intensity  most 
materially  in  different  patients,  and  the  student  should  first  endea- 
vour to  catch  the  sound  about  the  inner  edge  and  angle  of  the  sca- 
pula on  the  healthy  side  if  he  suspect  one  to  be  diseased:  then  to 
compare  this  with  the  other:  from  thence  he  may  trace  it  upwards 
and  downwards  and  to  either  side,  listening  at  the  same  time  to  the 
sound  of  the  voice.  It  is  a  good  plan  to*  get  the  patient  to  talk 
continuously  on  some  subject;  because,  not  only  is  the  voice  thus 
heard,  but  at  the  end  of  each  sentence  a  deeper  inspiration  is  made, 
wrhich  thus  becomes  audible,  when,  as  it  sometimes  happens,  the  na- 
tural murmur  is  so  weak  as  scarcely  to  be  heard  at  all:  practically, 
I  think  this  plan  more  convenient  than  causing  'him  to  count  one, 
two,  three,  &c,  as  many  auscultators  do;  the  latter  gives  more 
equal  intensity  to  the  sound  of  the  voice  than  general  conversation, 
but  minute  differences  in  vocal  resonance  are  not  of  much  value: 
it  is  important,  however,  in  all  cases  to  hear  the  natural  respiration 
if  possible  without  the  intermixture  of  the  sound  of  the  voice. 

§  1.  Fercussion  elicits  a  marked  difference  in  resonance  between 
the  two  sides,  with  much  resistance  on  the  duller  side. 

A.  There  is  no  breathing  at  all  to  be  heard  at  the  base  of  the 
lung,  on  the  dull  side;  at  a  higher  level,  varying  in  different  cases, 
it  first  becomes  audible;  and  at  the  upper  part  prolonged  expiration 
is  heard  louder  on  the  dull  side  posteriorly  just  as  it  is  in  the  clavi- 
cular region  (Div.  I.,  §  1,  A:)  the  voice-sound  is  exaggerated  and 
ringing  at  the  upper  part,  and  at  one  particular  elevation  it  has  a 
peculiar  tremor  and  shakiness,  which  has  received  the  name  of 
pegophony.  These  circumstances  enable  us  to  determine  that  the  ab- 
sence of  breath-sound  is  caused  by  the  effusion  of  fluid  and  conse- 
quent compression  of  the  lung. 

B.  The  breath-sound  is  nowhere  wholly  inaudible,  or  at  all  events 
is  heard  so  low  down  that  there  must  be  a  doubt  whether  it  be  any- 


THE  POSTERIOR  AND  LATERAL  REGIONS.     207 

where  abolished:  it  has  a  blowing  sound,  and  is  harsh  and  distinct, 
the  expiration  being  especially  prolonged:  the  voice-sound  is  heard 
low  down  in  the  chest,  with  a  ringing  brassy  quality,  which  is  con- 
stantly taken  for  tegophony,  but  it  is  diffuse  and  nowhere  exhibits 
the  true  characteristic  vibration  of  that  sound.  It  is  to  be  observed 
that  the  marked  dulness  and  resistance  are  more  than  consolidation 
alone  could  produce,  and  yet  the  characters  of  the  voice  and  breath- 
sound  are  such  as  have  been  already  mentioned  as  indicative  of  in- 
creased conducting  power  of  lung-tissue  by  which  the  sounds  pro- 
duced in  the  larger  tubes  are  conveyed  to  the  ear;  it  is  therefore 
reasonable  to  conclude  that  there  is  effusion  of  fluid  along  with  con- 
solidation of  lung. 

c.  The  percussion  sound  is  superficially  somewhat  resonant,  but 
very  distinct  dulness  is  observed  when  the  stroke  is  firm  and  forci- 
ble: the  breath  and  voice-sounds  are  not  much  changed,  except 
that  the  vesicular  breathing  is  generally  weak  on  the  affected  side, 
and  is  combined  with  a  sound  of  distant  blowing.  The  phenomena 
are  the  same  as  those  referred  to  in  the  clavicular  region  (Div.  I., 
§  1,  B.  c. ;)  and  the  diagnosis  of  deep-seated  tumour,  so  far  as  aus- 
cultation is  concerned,  really  rests  simply  on  such  a  state  of  things 
being  found  pretty  generally  throughout  one  lung. 

§  2.  Percussion  indicates  a  marked  difference  between  the  two 
sides  of  the  chest,  one  of  them  being  unusually  resonant. 

A.  The  breathing  is  heard  with  a  loud  blowing,  amphoric  sound ; 
the  voice  has  a  similar  character;  the  percussion  resonance  while 
tympanitic,  has  commonly  a  hard  wooden  tone,  in  pneumo-thorax. 

b.  The  breathing  may  be  inaudible  while  the  other  characters  re- 
main the  same.  These,  like  the  corresponding  cases  in  Div.  I.,  are 
also  produced  by  the  presence  of  air  in  the  pleura;  and  it  is  when 
the  evidence  obtained  from  the  posterior  and  lateral  regions  is  ana- 
logous to  that  of  the  clavicular  regions,  that  we  can  alone  deter- 
mine its  existence  with  certainty. 

C.  Very  rarely  do  we  find  the  clear  elastic  resonance  of  emphy- 
sema on  one  side  contrasting  very  strikingly  with  the  percussion 
stroke  on  the  other;  most  commonly  the  affection  extends  to  both 
lungs;  the  inspiration  is  generally  inaudible,  and  the  expiration 
characterized  by  one  or  other  of  the  signs  of  bronchitis,  or  heard 
as  a  distant  blowing  sound:  the  voice-sound  is  less  distinct  than 
usual. 

§  3.  The  dulness  on  percussion  being  less  marked, — 

A.  The  expiration  is  prolonged,  and  the  voice-sound  exaggerated 
where  the  dulness  is  observed,  just  as  we  have  already  mentioned 
in  similar  consolidation  under  the  clavicle. 

B.  A  slight  amount  of  emphysema  of  one  lung  produces  effects 
similar  to  those  mentioned  in  Div.  I. ;  louder  breath  and  voice-sound 
on  the  duller  side,  without  any  character  of  harshness  or  alteration 


208  AUSCULTATION    AND    PERCUSSION. 

of  rhythm:  prolonged  expiration  is  rather  to  be  heard  on  the  more 
iniit  side;  but,  except  it  be  accompanied  by  some  form  of  su- 
peradded sound,  this  condition  is  not  one  of  any  importance. 

c.  In  inflammation  attended  with  pain,  the  motion  of  the  ribs  is 
interfered  with,  and  there  is  slight  dulness  and  want  of  breathing, 
while  the  voice  is  generally  exaggerated:  if  a  forced  inspiration  be 
taken  we  perhaps  obtain  the  friction-sound  of  pleurisy  or  the  crack- 
ling of  pneumonia. 

D.  The  breathing  is  sometimes  weaker  on  one  side  below;  as  we 
ascend,  it  becomes  more  audible,  but  is  harsh  and  unnatural;  and 
above,  loud  blowing  breath-sound  is  heard  more  distinctly  at  one 
apex  than  the  other;  the  voice  is  always  unnaturally  loud.  Both 
lungs  are,  in  truth,  partially  affected,  but  in  one  the  signs  of  disease 
are  much  more  evident:  this  is  the  character  of  acute  tuberculosis; 
it  is  always  accompanied  by  corresponding  changes  in  the  clavicu- 
lar region. 

§  4.  No  difference  is  any  where  detected  on  percussion  between 
the  two  sides. 

a.  The  resonance  may  be  natural. 

a.  The  indications  of  disease  derived  from  auscultation  are  limit- 
ed to  the  apex,  where  they  confirm  the  conclusions  already  arrived 
at  in  examining  the  clavicular  region.  A  delicate  ear  may  make 
out  dulness  in  the  supra-scapular  fossa ;  but  cases  continually  present 
themselves  in  which  it  is  not  possible  for  the  majority  of  persons 
to  do  so. 

b.  On  one  or  both  sides  the  superadded  sounds  of  mucus  in  the 
smaller  bronchi  may  be  heard,  when  there  is  no  change  whatever 
in  the  density  of  the  lung;  this  commonly  happens  in  bronchitis. 

B.  Both  sides  may  be  unusually  resonant;  the  chest  full  and 
rounded,  the  scapulre  far  apart,  and  little  movement  comparatively 
observed  in  breathing;  the  breath  and  voice-sounds  are  both  weak, 
or  almost  null,  perhaps  some  distant  blowing  expiration  is  audible; 
very  commonly  superadded  sounds  are  detected.  If  similar  circum- 
stances have  pointed  to  emphysema  in  the  clavicular  region,  the 
diagnosis  becomes  certain. 

c.  Both  sides  may  be  somewhat  duller  than  natural:  rarely,  in- 
deed, equally  so  on  both  sides,  but  still  such  as  not  to  be  very  dis- 
tinctly different.  This  may  occur  in  oedema  of  the_  lungs,  double 
pneumonia,  and  general  tuberculosis;  the  difference  is  least  in  the 
first  of  these  affections  and  greatest  in  the  last,  in  which,  over  th*e 
scapula  and  under  the  clavicle,  it  can  almost  always  be  made  out : 
when  the  lungs  are  ©edematous,  the  superadded  sounds  leave  us  in 
no  kind  of  doubt;  in  pneumonia  the  dulness  can  often  be  determined 
by  percussion  in  the  axillary  region  when  it  cannot  be  made  out 
posteriorly.  In  any  of  these  cases  the  presence  of  superadded 
sound,  or  a  contrast  between  the  loudness  and  rhythm  of  the  breath- 
ing, suffice  to  prove  4hat  there  is  something  wrong,  and  we  must 
assume  that  they  in  reality  belong  to  the  next  class. 


THE    POSTERIOR    AND    LATERAL    REGIONS.  209 

D.  The  difference  on  percussion  is  not  observed.  This  does  not 
form  such  an  important  class  as  it  did  in  Div.  I.,  because  the  early 
detection  of  insidious  disease  can  seldom  be  accomplished  except  in 
the  clavicular  region.  With  reference  to  changes  in  the  breath  and 
voice-sounds,  when  we  cannot  make  out  any  difference  on  percus- 
sion, it  is  to  be  remembered  (1)  that  at  the  upper  part  of  the  chest 
behind,  too  much  importance  must  not  be  assigned  to  them,  when 
they  seem  to  be  normal  in  the  clavicular  region,  because  of  the 
distribution  of  the  large  tubes  towards  the  back  of  the  lungs:  (2) 
that  at  the  lower  part  of  the  chest  the  voice-sound  is  of  compara- 
tively little  value,  because  of  the  distance  from  the  larynx ;  but  in 
deep-seated  pneumonia  this  is  sometimes  the  only  sign  we  obtain 
confirmatory  of  the  evidence  of  general  symptoms:  (3)  the  mere 
weakening  of  breath-sound  by  emphysema,  when  increased  reso- 
nance is  not  perceived,  is  of  very  slight  moment,  except  in  so  far 
as  it  accounts  for  bronchitis  being  limited  to  one  side  of  the  chest: 
it  is  also  to  be  borne  in  mind  as  affording  an  explanation  of  defi- 
cient respiration ;  because  (4)  in  pleurisy,  before  dulness  can  exist, 
the  breathing  is  suppressed,  and  the  distinction  between  the  two 
depends  chiefly  on  the  history,  and  the  presence  or  absence  of  pain 
and  fever. 

Of  the  cases  mentioned  under  §  1,  it  is  to  be  remarked  that  no  condition  of  lung 
gives  such  a  dull,  dead  percussion  sound,  with  manifest  resistance,  as  that  which 
is  due  to  pleuritic  effusion;  the  multiplying  of  evidences  of  its  existence  is  there- 
fore unnecessary,  but  its  amount  may  be  judged  of  by  the  bulging,  more  or  less, 
of  the  intercostal  spaces,  the  lateral  displacement  of  the  heart,  ihe  space  over 
which  breathing  can  be  heard,  and  the  downward  displacement  of  the  abdominal 
viscera. 

The  term  osgophony  is  one  of  the  opprobria  of  auscultation ;  and  yet  it  has  be- 
come so  consecrated  by  use,  that  it  is  difficult  to  see  how  it  can  be  got  rid  of:  the 
name  conveys  no  idea  of  the  sound,  but  is  so  completely  associated  in  the  mind 
with  the  thought  of  pleuritic  effusion,  that  it  cannot  be  applied  without  suggest- 
ing a  theory  of  the  nature  of  the  disease;  it  is  therefore  quite  as  objectionable  as 
any  other  word  which  more  explicitly  asserts  the  condition  of  the  iung  (c.  r/.,  ca- 
vernous.) It  is  quite  true  that  when  the  sound  has  been  fully  learnt,  it  will  be  re- 
cognised in  its  perfect  form,  under  no  other  circumstances;  but  the  resonance  of 
the  voice  is  most  commonly  increased  when  there  is  dulness  on  percussion,  and 
often  acquires  a  ringing  or  even  a  shaky  quality,  which  closely  resembles  ajgo- 
phony,  and  is  constantly  mistaken  for  it.  In  using  the  term  it  must  be  limited  to 
those  cases  only  in  which,  over  a  small  extent  of  lung  surface,  a  hollow,  squeaking, 
tremulous  voice-sound  is  heard,  which  above  and  below  passes  into  something  else. 

Sometimes,  in  consequence  of  the  lung  being  fastened  down  to  some  part  of  the 
chest  by  old  adhesion,  the  breath  will  be  heard  unusually  low  in  cases  of  sim- 
ple effusion,  especially  near  the  spine :  this  source  of  fallacy  must  be  borne  in  mind, 
and  an  examination  of  the  lateral  region  will  give  sufficient  evidence  of  the  pre- 
sence of  fluid. 

The  condition  of  the  lung  is  very  different  in  consolidation  and  compression  ; 
the  one  being  a  deposit  within,  the  other  a  pressure  from  without;  in  both,  the 
vesicles  may  be  equally  obliterated,  and  the  mass  equally  solid  and  heavy;  but  in 
the  one  there  is  no  loss  of  size,  and  all  the  tubes  are  patent ;  in  the  other  all  the 
minor  tubes  at  least  are  collapsed  as  well  as  the  vesicles.  This  circumstance 
fully  explains  the  inci'eased  breath-sound  as  heard  in  consolidation  compared  with 
that  heard  in  compression. 

In  a  case  in  which  there  is  consolidation  of  the  lower  lobe  along  with  effusiou 

14 


210  3CULTATION    -VXD    PERCUSSION. 

of  fl aid,  the  upper  lobe  mast  suffer  compression  to  allow  space  for  its  presence, 

firm  ;ui<l  incompressible:  in  it  the  tubes  remain  opt  n  while 

1 :  and  hence  the  diffuse  blowing,  and  the  diffusi  exag- 

which  has  been  notice!.     Superadded  Bound  is  very  commonly 

lit:  in  pleuro-pnenmonia  it  will  be  beard  as  the  line,  crackling  sound  called 

itation;  in  oedema  of  the  lungs  with  passive  effusion,  as  a  coarser  sound, 

which  is  never  wanting:  the  oedematous  condition  seems  to  be  one  rather  op|  ■ 

to  the  production  of  aegophony,  which  often  cannot  be  heard  when  there  is  clear 

evidence  of  lluid  in  the  pleura. 

When  a  tumour  is  deeply  seated  in  the  lung,  the  dulness  is  diffuse,  with  little 
sense  of  resistance,  and  conies  out  more  distinctly  on  firm  percussion;  the  breath- 
ing is  weak  but  superficial,  not  otherwise  changed  except  that  it  is  less  audible 
than  on  the  opposite  side;  a  blowing  sound  will  be  heard  when  the  tumour  presses 
on  one  of  the  larger  tubes,  and  i:  Beems  to  be  conveyed  to  the  ear  from  a  distance, 
in  addition  to  the  weak  vesicular  breathing  heard  at  the  surface;  the  distant  blow- 
ing may  also  be  detected  at  the  back  of  the  other  lung. 

The  diagnosis  of  the  cases  referred  to  in  §  2  is  much  aided  by  the  character  of 
the  superadded  sounds  which  are  commonly  preseut.  This  is  especially  remark- 
able iu  cases  of  pneumo-thorax;  and  in  emphysema  we  know  that  bronchil 

.  and  gives  rise  to  the  various  sounds  of  that  disease.  In  the  first  burst- 
ing of  air  into  the  cavity  of  the  pleura,  the  intense  dyspnoea  which  it  suddenly  pro- 
sterminea  at  once  the  interpretation  we  ought  to  give  to  the  tympanitic 
percussion  sound;  subsequently  the  invariable  sequence  of  pleurisy  and 
— bydro-pneumo-thorax — is  attended  by  other  very  peculiar  sounds,  technically 
called  the  sound  of  succussion  and  metallic  tinkling.  The  loudness  of  the  breath- 
ing, anteriorly  or  posteriori)*,  depends  entirely  on  the  position  of  the  aperture  by 
which  the  air  enters,  and  its  continuing  open  or  not. 

Emphysema  commonly  affects  both  lungs,  though  not  equally,  its  weak,  pro- 
jed  expiratory  sound  can  scarcely  ever  be  mistaken  for  the  peculiar  amphoric 
echo  of  pneumo-thorax.  and  the  absence  of  voice-sound  in  the  one  contrasts 
strikingly  with  its  metallic  reverberation  in  the  other:  not  less  different  is  the  clear 
resiliency  of  the  percussion  sound  in  emphysema  from  that  wooden  hollowness  which 
the  tympanitic  resonance  of  pneumo-thorax  acquires  from  inflammation  of  the 
pleura  consequent  on  the  admission  of  air. 

Under  §  3  there  is  not  the  same  liability  to  error  that  we  found  in  the  same  class 
in  the  clavicular  region;  the  differences  observed  on  percussion  are  less  delicate, 
and  the  early  deposit  of  tubercle  cannot  be  traced  in  the  other  parts  of  the  lung. 
"When  dulness  is  perceptible,  we  have  a  more  advanced  form  of  disease,  and  there 
is  not  the  same  chance  of  error  in  mistaking  its  seat,  when  that  happens  to  be  on 
the  more  resonant  side;  still,  it  must  be  remembered,  that  the  character  by  which 
we  recognise  an  emphysematous  lung  is  the  combination  of  deficient,  al; 
breathing  with  increased  percussion  resonance:  all  other  morbid  states  cognizable 
by  percussion  at  the  posterior  and  lateral  parts  of  the  chest  belong  to  those  in 
which  dulness  and  altered  breathing  go  together.  The  respiration  is  weak  and 
imperfect,  or  loud  and  harsh,  over  the  seat  of  dulness;  and  according  to  the  ex- 
tent to  which  vesicular  breathing,  however  imperfect,  is  heard,  do  we  determine 
whether  the  disease  affects  the  superficial  or  the  deeper-seated  structure  of  the 
lung,  except  when  pain  puts  a  stop  to  the  ordinary  movement  of  the  ribs  on  the 
affected  side;  but  this  very  fact  is  one  of  the  elements  of  diagnosis,  and  corrects 
our  hypothesis  of  the  condition  of  disease.  It  is,  however,  worthy  of  notice  that, 
as  compared  with  indications  derived  from  the  clavicular  region,  the  dulness  on 
percussion,  which  seems  only  to  be  of  slight  amount,  may  be  accompanied  by 
changes  of  breath  and  voice-sound  which  were  only  noticed  as  belonging  to  marked 
dulness  in  front.  We  have  to  do  with  causes  of  consolidation  in  many  respects 
analogous  to  those  mentioned  in  Div.  I.;  but  that  of  mere  compression  may  be 
excluded,  because  at  the  lower  part  of  the  chest  we  have  in  such  cases  the  evi- 
dence of  the  presence  of  the  fluid  which  produces  it. 

One  condition  only  is  specified  as  being  traceable  by  the  modification  of  the 
breathing  and  the  percussion  resonance;  and  this  not  because  there  is  any  thing 
.specific  in  the  one  or  the  other,  but  simply  from  the  pathological  fact,  that  when 


SUMMARY.  211 

the  deposit  is  so  distributed  as  to  produce  general  imperfect  dulness  and  obstruc- 
tion of  the  vesicular  breathing,  while  the  tissue  has  not  become  so  solid  as  to  trans- 
mit loudly  the  blowing  sounds  of  the  large  tubes,  except  perhaps  at  the  apex,  its 
character  will  be  found  after  death  to  be  tubercular  and  not  fibrinous.  The  dis- 
covery of  a  similar  condition  in  minor  degree  at  the  apex  of  the  other  lung  puts 
this  question  beyond  doubt. 

The  absence  of  any  perceptible  difference  in  percussion  between  the  two  lungs, 
as  referred  to  in  \  4,  is  a  more  constant  condition  in  diseased  states  at  the  posterior 
and  lateral  parts  of  the  chest  than  in  front,  but  it  is  also  less  material  to  ascertain 
the  more  minute  differences,  which  are  indeed  in  great  measure  not  to  be  recog- 
nised by  the  student.  When  evidence  of  disease  at  one  apex  has  been  obtain,  d 
anteriorly,  the  breath  and  voice-sounds  may  differ  more  or  less  throughout  the 
whole  extent  of  the  lung;  but  when  in  the  lower  lobes  they  are  exactly  equal* on 
both  sides,  we  feel  great  certainty  in  the  diagnosis  of  phthisis.  If  the  difference 
in  percussion  be  not  perceived,  although  really  existing,  as,  for  example,  in  gene- 
ral emphysema,  in  dulness  affecting  both  sides  of  the  chest,  or  in  the  early  stages 
either  of  consolidation  or  dilatation,  a  correlative  difference  may  yet  be  traced  in 
the  breath  and  voice-sounds,  sometimes  with  and  sometimes  without  super-added 
sound  ;  and  we  must  endeavour  to  ascertain  the  general  character  of  the  breathing 
in  the  individual  who  happens  to  be  under  examination,  contrasting  this,  as  the 
standard,  with  that  heard  on  each  side  where  the  difference  has  been  detected; 
that  which  deviates  most  is  sure  to  be  the  seat  of  disease ;  the  voice  may  then 
help  to  determine  whether  it  tend  towards  consolidation  or  towards  dilatation. 

At  the  upper  part  of  the  chest  it  is  important  to  remember  the  natural  tendency 
to  loudness  on  the  right  side,  and  this  is  especially  remarkable  over  the  spine  of 
the  scapula;  but  any  where  near  the  bifurcation  of  the  trachea,  owing  to  the  dif- 
ferent direction  of  the  bronchi  on  the  two  sides,  local  loudness,  even  when  it  has  a 
blowing  character,  may  be  disregarded.  At  the  bases  in  chronic  states,  difference 
of  breathing  without  superadded  sounds  are  of  minor  importance  when  no  dulness  is 
made  out;  in  acute  cases,  the  early  checking  of  the  respiratory  movement  in  pleurisy, 
and  the  absence  of  almost  any  indication  in  deep-seated  pneumonia,  should  not 
be  forgotten.  It  sometimes  happens  that  very  distinct  evidence  from  general 
symptoms  is  obtained  of  the  existence  of  pneumonia  when  the  only  auscultatory 
phenomenon  consists  of  a  diffuse  voice-sound,  reaching  the  ear  more  loudly  on  the 
affected  side ;  the  breathing  may  be  equal  to,  or  only  very  little  weaker  than  that 
on  the  opposite  side  ;  occasionally  more  careful  auscultation  may  detect  some- 
where or  other  a  distant  blowing  sound  proceeding  from  the  consolidated  portion, 
which  is  not  altogether  concealed  by  the  vesicular  murmur. 

Summary. 

Percussion  resonance  and  changes  in  the  breath  and  voice-sounds 
serve  to  point  out  the  greater  or  less  relative  density  of  the  con- 
tents of  the  chest ;  and  it  is  very  important  for  the  student  to  learn 
to  reason  logically  upon  the  indications  thus  presented  to  him.  We 
have  therefore  kept  out  of  view  for  the  present  all  the  additional 
information  which  superadded  sounds  necessarily  convey,  because 
the  first  question  to  be  solved,  before  assigning  a  cause  for  any 
such  sound,  is  whether  there  be  or  be  not  any  change  of  structure, 
any  increase  or  diminution  in  the  solids,  the  fluids,  or  the  air  of 
that  part  where  the  abnormal  sound,  whatsoever  it  may  be,  is  heard. 
We  find,  then,  that  the  lung  itself  may  be  either  more  or  less  dense, 
and  the  pleura  may  contain  either  fluid  or  air:  or  we  may  have,  for 
example,  in  advanced  phthisis,  dense  lung  surrounding  a  hollow 
cavity;  and  in  bydro-pneumo-thorax  both  air  and  fluid  in  the 
pleura. 


212  AUSCULTATION    AND    PERCUSSION. 

§  1.  Condensation  presents  itself  in  three  forms:  (1)  carnifica- 
tion,  when,  from  mere  pressure,  the  air  is  excluded  from  the  vesicles, 

I  only  permeates  those  larger  tubes  which  are  kept  open  by  their 
own  elasticity;  the  most  prominent  example  of  this  class  is  the 
leathery  lung  of  pleurisy  with  no  accompanying  pneumonia:  an 
analogous  condition  is  found  in  some  instances  where  the  pressure 
is  caused  by  a  tumour,  and  we  may  regard  in  the  same  light  the 
atelectasis  of  newT-born  children,  the  pressure  in  this  case  being 
dimply  atmospheric,  the  inspiratory  act  not  having  sufficient  power 
to  force  the  air  into  the  minute  tubes.  (2)  Hepatization:  the  pa- 
renchyma of  the  lung  is  solidified  by  an  effusion  of  coagulable 
lymph,  which  occludes  the  vesicles,  but  does  not  fill  up  any  of  the 
tubes;  the  only  real  representative  of  this  form  is  pneumonia: 
cedema,  and  engorgement  of  the  lungs,  which  are  both  passive 
states,  although  increasing  to  a  small  extent  the  relative  density  of 
the  tissue,  do  not  produce  the  same  occlusion  of  the  vesicles,  and 
do  not  give  rise  to  similar  auscultatory  phenomena;  the  condensa- 
tion from  these  causes  is  rarely  such  as  to  produce  definite  dulness 
on  percussion.  (3)  Tuberculization,  which  is  seen  under  very  dif- 
ferent aspects,  either  as  minute  deposits  separated  by  certain  inter- 
vals, and  in  so  far  obstructing  either  vesicles  alone,  or  vesicles  and 
tubes  ton-ether,  or  as  aggregated  into  masses,  some  of  which  have 
been  expelled  and  have  left  hollow  spaces  remaining;  or,  again, 
what  is  very  rare,  as  a  uniformly  diffused  deposit,  closely  analogous 
to  that  of  coagulable  lymph.  Percussion  resonance  can  only  show 
that  the  condensed  lung  is  more  solid  than  its  fellow,  and  may  give 
a  rough  estimate  of  the  extent  to  which  air  is  excluded;  but  it  is 
quite  a  mistake  to  suppose  that  it  can  ever  discriminate  the  cause 
of  its  exclusion:  auscultation  reveals  more  definitely  the  extent  to 
which  the  air  penetrates  the  lung,  and  also  teaches  us  how  far  the 
tissue  is  changed  as  a  medium  for  the  formation  and  transmission 

of  sound. 

In  each  of  these  forms  of  condensation  the  proper  vesicular  mur- 
mur is  wanting.  In  the  first  the  sounds  are  similar  to  those  heard 
over  a  healthy  trachea,  but  deadened  by  passing  through  the  tough 
inelastic  tissue  placed  between  the  large  tubes  and  the  ear;  the 
inspiration  and  expiration  are  both  loud  and  harsh,  and  the  voice 
ringing,  and  these  sounds  are  diffused  over  the  whole  space  where 
the  carnified  lung  exists;  except  where  the  voice  is  so  modified  by 
the  presence  of  fluid  in  the  pleura,  as  to  acquire  the  quality  which 
has  been  denominated  a>gophony.  In  the  second  the  breathing 
gives  rise  to  a  peculiar  whiffing  sound  as  it  enters  the  small  tubes, 
the  sides  of  which  have  acquired  hardness  and  increased  vibratory 
power  from  the  effusion  of  lymph  around ;  and  it  is  readily  trans- 
mitted to  the  ear  through  the  dense  elastic  structure:  the  voice  has 
at  the  same  time  a  very  loud,  sonorous,  and  metallic  or  brassy 
sound,  from  the  same  circumstances,  and  is  diffused  over  the  whole 
hepatized  portion  of  the  lung.     In  the  third  the  characters  vary 


SUMMARY.  213 

very  much  according  to  the  amount  and  the  state  of  the  deposit: 
in  the  early  stage  the  breathing  is  heard  in  smaller  tubes  than  in 
carnification,  and  does  not  produce  in  them  the  whiffing  sound  of 
hepatization ;  the  voice  is  not  ringing  as  in  the  one,  nor  metallic  as 
in  the  other;  there  is  indeed  a  period  in  tubercular  deposit  in  which 
modified  vesicular  breathing  is  heard,  while  no  marked  change  has 
passed  on  the  voice  at  all;  proceeding  further,  the  vesicular  breath- 
ing is  more  or  less  suppressed,  and  the  lung  acquires  greater  power 
of  transmitting  sound,  so  that  the  breathing  and  the  voice,  which 
properly  belong  to  the  bronchial  tubes,  are  heard  at  the  surface, 
and  are  therefore  louder  and  harsher  than  in  health:  this  gradually 
increases  in  intensity,  till  the  tubes  are  encroached  upon,  when  the 
breath-sound  becomes  more  faint,  and  their  elasticity  being  lost,  the 
expiration  is  prolonged;  at  the  same  time  consolidation  has  pro- 
ceeded to  a  greater  extent,  and  the  voice-sound  is  therefore  louder: 
next,  the  foreign  matter  softens  and  is  expelled,  the  air  begins  to 
vibrate  in  larger  spaces,  and  the  breath-sound  becomes  louder, 
harsher,  and  more  blowing;  till  at  length  the  large  cavity,  with  un- 
yielding walls,  gives  out  a  long,  loud,  blowing  inspiratory  and 
expiratory  sound:  at  the  same  time  the  voice-sound  attains  such 
loudness  and  distinctness  that  it  seems  as  if  it  were  produced  at 
that  very  spot,  and  spoken  up  through  the  stethoscope  to  the  ear. 
As  might  be  anticipated,  in  the  rarer  cases  in  which  tubercle  is 
deposited  in  the  same  way  as  lymph,  the  auscultatory  phenomena 
are  also  analogous. 

In  each  of  these  cases  diagnosis  is  aided  by  several  other  cir- 
cumstances: in  carnification  by  evidence  of  the  presence  of  fluid 
or  air  in  the  pleura  or  of  some  solid  substance  which  has  pressed 
on  the  lung  and  expelled  the  air  from  its  vesicles ;  in  hepatization 
by  the  lower  and  back  parts  being  more  commonly  affected;  in 
tuberculization  by  the  upper  lobe  being  first  or  most  extensively 
diseased.  The  difficulties  are  chiefly  connected  with  the  revefting 
of  the  ordinaiy  rule  regarding  situation  and  the  combination  of 
two  conditions  of  condensation — carnification  with  hepatization,  or 
with  tubercles;  tuberculization  with  hepatization;  or  even  all  three 
together.  "We  have  also  to  consider  the  condition  of  the  opposite 
lung:  when  the  breathing  is  much  obstructed  on  one  side,  it  is 
usually  exaggerated  on  the  other — puerile  as  it  is  often  miscalled; 
and  if  it  be  equable  throughout,  the  disease  is  probably  not  tuber- 
cular: if  the  apex  of  the  comparatively  healthy  side  be  affected, 
the  opposite  lung  is  almost  certainly  in  a  state  of  tuberculization ; 
if  the  sounds  at  its  base  be  changed,  the  cause  of  disease  in  the 
other  is  probably  inflammation. 

§  2.  In  cases  in  which  the  lung  has  become  less  dense  than  na- 
tural, it  is  immaterial  whether  the  vesicles  be  distended,  as  in  the 
common  form  of  emphysema,  or  the  air  pass  into  the  parenchyma 
of  the  lungs,  as  happens  when  its  structure  is  torn :  the  natural 
elasticity  which  expels  the  air  at  each  expiration  is  lost  in  either 


214  AUSCULTATION   AND    TERCUSSION. 

case,  the  air  stagnates,  and  the  vesicular  murmur  is  no  longer  aucli- 
ble:  the  sound  of  air  moving  in  the  large  tubes  would  indeed  be 
heard  distinctly,  were  it  not  that  the  rarefied  tissue  has  become  a 
bad  conductor;  and  hence  it  is  only  when  superadded  sounds  indi- 
cate the  motion  of  the  air,  or  when  the  tubes,  thickened,  roughened, 
or  dilated,  cause  unusual  vibration,  as  it  passes  to  and  fro,  that  the 
distant  sounds  reach  the  ear  at  all  plainly:  the  voice  meets  with 
the  same  obstacle  to  its  transmission,  and  is  only  heard  when  the 
tubes  are  thickened  or  dilated.  The  superadded  sounds  therefore 
stand  with  many  for  the  evidence  of  emphysema,  while  in  reality 
they  are  so  only  secondarily:  the  thickening  and  dilatation  of  the 
tubes,  and  the  increased  voice  and  breath-sound  which  accompany 
them,  are  frequent  sources  of  fallacy. 

§  3.  No  other  condition  of  disease  exactly  simulates  the  dead, 
dull,  inelastic  sound  of  percussion,  and  the  sense  of  resistance 
which  is  produced  by  the  presence  of  fluid  in  the  pleural  cavity: 
occupying  as  it  always  does  the  inferior  part,  the  intensity  of  the 
dulness  gradually  diminishes  towards  the  apex,  but  of  course  it 
varies  with  the  amount  of  fluid;  and  inasmuch  as  pleurisy  does  not 
necessarily  imply  the  presence  of  fluid,  the  dulness  may  be  caused 
by  effusion  of  lymph  only.  ^Yhen  this  is  the  case,  the  dull  sound 
is  mixed  up  with  a  certain  degree  of  resonance,  which  has  been 
compared  to  that  of  striking  on  wood;  one  which  in  its  greatest 
intensity  is  best  heard  when  there  is  a  thickened  pleura  with  air  in 
its  cavity.  If  there  be  no  accompaniment  of  pneumonia,  the  lung 
is  simply  carnified  from  pressure ;  it  is  pushed  upwards,  and  hence 
the  sounds  belonging  to  this  condition  are  most  distinctly  to  be  made 
out  under  the  clavicle;  somewhere  over  the  scapula  regophony  is 
met  with.  "When  pneumonia  is  also  present  the  tubes  remain  more 
generally  permeable  to  air,  and  the  voice-sound  is  diffuse,  somewhat 
metallic  or  brassy,  but  modified  by  the  superstratum  of  fluid,  so  as 
to  ajfproach  to  jvgophony ;  it  differs  from  this  essentially,  however, 
in  that  it  is  diffuse  and  not  local. 

The  tympanitic  percussion  sound  of  air  in  the  pleura  is  very 
rarely  pure;  there  is  almost  always  a  thickened  membrane,  which 
gives  a  wooden  tone  to  the  resonance,  and  fluid  usually  exists  at  the 
base.  Percussion  over  a  large  cavity  has  an  amphoric  or  cracked- 
pot  resonance,  which  is  somewhat  analogous,  but  no  mistake  need 
occur  from  this  cause  if  any  degree  of  care  be  used;  because  at 
the  lower  and  back  parts  breathing,  probably  much  altered  and 
mixed  with  superadded  sounds,  can  be  detected  where  there  is  only 
a  cavity  at  the  apex,  while  none  can  be  heard  in  pneumo- thorax, 
save  where  the  air  escaping  from  the  lung  causes  the  long  amphoric 
blowing  of  expiration. 


215 


CHAPTER  XIX. 

SUPERADDED    SOUNDS   IN   THEIR    RELATION   TO   ALTERED   BREATH 

AND    VOICE-SOUNDS. 

Classification. — §  1,  Interrupted  Sounds — §  2,  Continuous  Sounds. 

Div.  I. —  The  Clavicular  Region. — §  1,  With  marked  Dulness  on 
one  side — §  2,  xuith  excessive  Resonance — §  3,  with  less  marked 
Difference  on  Percussion — §  4,  with  no  perceptible  Difference. 

Div.  II. — The  Posterior  and  Lateral  Regions. — §  1,  With  marked 
Dulness  on  one  side — §  2,  with  excessive  Resonance — §  3,  with 
less  distinct  Difference — §  4,  with  no  perceptible  Difference. 

Summary.  The  real  Teaching  and  relative  Value  of  superadded 
Sounds. 

We  have  next  to  consider  what  further  light  is  afforded  by  su- 
peradded sounds  as  to  the  causes  of  that  change  of  structure 
Avhich  has  been  indicated  by  alterations  in  breath  and  voice-sound 
and  in  percussion  resonance ;  and  also  what  they  teach  us  concern- 
ing the  state  of  the  lungs,  in  cases  in  which  we  have  been  unable 
to  detect  any  change  of  density. 

Various  modes  of  classification  have  been  adopted  by  different 
authors,  but  they  have  all  been  framed  more  or  less  on  theories  re- 
garding the  mode  of  development,  either  with  reference  to  the  situ- 
ation in  which  the  sound  is  supposed  to  be  generated,  or  to  the 
amount  of  fluid  assumed  to  be  necessary  for  its  production.  The 
names  which  authors  have  thus  either  fancifully  or  theoretically 
imposed  upon  these  sounds  have  too  often  only  served  to  mislead 
the  student,  by  causing  him  to  attach  the  idea  of  a  particular  con- 
dition of  disease  to  the  name  of  some  given  sound,  or  by  rendering 
it  impossible  to  understand  the  exact  character  of  one  upon  which 
various  names  have  been  bestowed.  We  have  endeavoured  in  the 
preceding  chapter  to  limit  the  names  used  to  terms  expressing  the 
character  of  the  sound  heard,  and  the  same  course  will  be  followed 
with  reference  to  this  new  class  of  phenomena,  in  so  far  as  it  can 
be  done  without  roughly  discarding  customary  terms.  Perhaps 
there  is  no  advantage  in  classification  at  all,  but  it  may  tend  to 
simplify  matters  if  the  superadded  sounds  be  divided  into  inter- 
rupted and  continuous — including  in  the  former  those  that  consist 
of  a  series  of  distinct  noises  or  minute  explosions,  and  in  the  latter 
those  that  form  only  one  prolonged  sound. 

§  1.  Interrupted  Sounds. 

a.  Crepitation  consists  of  a  succession  of  fine  crackling  sounds, 
commonly  so  minute  and  so  close  together  that  the  ear  can  scarcely 
detect  their  distinctness. 


216  AUSCULTATION  —  SUPERADDED    SOUNDS. 

I.  Moist  Sounds;  the  least  objectionable  term  which  has  been  cra- 
ployed  to  designate  a  rattling  noise  in  which  the  separation  of  the 
individual  explosions  is  more  distinct  than  in  crepitation:  they  con- 
\r,  the  idea  of  air  passing  through  a  small  quantity  of  fluid  in 
minute  bubbles. 

c.  Gurgling  Sounds  are  only  a  modification  of  moist  sounds,  but 
are  yet  easily  recognised  as  a  class  by  themselves,  the  air  evidently 
gurgling  or  passing  in  large  bells  through  a  considerable  amount  of 
fluid. 

(/.  Metallic  Tinkling. — This  might  also  be  called  amphoric  drop- 
ping, conveying  to  the  ear  the  idea  of  distinct  drops  falling  with  a 
plash  in  a  large  space,  and  producing  a  ringing  metallic  noise. 

c.  Closely  connected  with  the  preceding  is  the  plashing  sound 
heard  when  the  patient  moves  quickly,  or  is  shaken,  in  cases  of 
hydro-pneumo-thorax.     It  is  called  the  sound  of  succussion. 

These  sounds  pass  by  insensible  degrees  into  each  other.  Cre- 
pitation may  be  so  very  fine  as  to  be  mistaken  for  a  continuous 
sound  (of  friction  for  example,)  or  it  may  be  so  very  coarse  as  to 
be  analogous  to  a  moist  sound;  theoretically  very  distinct,  the 
value  of  such  sounds  can  only  be  estimated  practically  by  the  co- 
existence of  other  phenomena.  Moist  sounds  may  be  divided  into 
fine  and  coarse;  they  hold  a  position  intermediate  between  crepi- 
tation and  gurgling.  Among  these  may  be  classed  a  sound  which 
has  been  very  inappropriately  called  dry  crackling,  which  consists 
of  single  clicks  recurring  at  longer  or  shorter  intervals ;  when 
speaking  of  it  apart  from  moist  sounds,  of  which  it  is,  in  certain 
circumstances,  the  precursor,  it  will  be  distinguished  by  this  cha- 
racter. Another  modification  is  the  squeaking  sound,  which  ap- 
proaches to  gurgling,  and  conveys  the  idea  of  a  large  bubble, 
formed  rather  in  consequence  of  the  viscidity  than  of  the  quantity 
of  fluid.  Gurgling,  again,  sometimes  consists  of  solitary  bubbles, 
at  very  considerable  intervals,  exploding  in  a  large  empty  cavity 
with  a  hollow  metallic  or  amphoric  ring,  which  is  scarcely  distin- 
guishable from  metallic  tinkling. 

§  2.   Continuous  Sounds. 

a.  Sonorous  and  Sibilant  Sounds. — These  consist  of  a  prolonged 
tone,  grave  or  shrill,  or  simply  of  a  continuous  hissing  noise,  ac- 
companying the  greater  part  of  the  act  of  inspiration  or  expiration, 
or  both  together,  but  chiefly  the  latter:  it  is  that  noise  which,  when 
loud  enough  to  be  heard  without  applying  the  ear  to  the  chest,  is 
called  wheezing.  The  depth  or  shrillness  of  the  note  indicates, 
within  certain  limits,  whether  the  sound  be  produced  in  larger  or 
smaller  tubes. 

b.  Friction  Sound,  caused  by  the  rubbing  together  of  two 
roughened  surfaces  of  pleura,  which,  in  their  healthy  state,  glide 
noix  lessly  over  each  other.  It  has  been  already  noticed  that 
crepitation  is  sometimes  so  fine  that  it  can  scarcely  be  distinguished 


THE    CLAVICULAR    REGION.  217 

from  friction,  when  the  ear  cannot  discriminate  the  distinct  explo- 
sions of  which  the  sound  is  composed.  In  a  similar  manner,  fric- 
tion may  be  so  coarse  as  to  be  mistaken  for  crepitation.  The  chief 
differences  are  these:  crepitation  is  more  deep-seated,  friction  more 
superficial;  fine  crepitation  accompanies  the  act  of  inspiration  only, 
is  quite  rhythmical  with  it,  and  terminates  with  it:  friction  may 
occur  at  any  period  of  the  respiratory  act,  is  very  commonly  heard 
both  with  inspiration  and  expiration,  or  is  intermediate  between 
them,  and  is  not  rhythmical  with  the  inspiration.  The  one  is  evi- 
dently part  of  the  sound  produced  by  the  movement  of  the  air  in 
the  lung  during  inspiration ;  the  other  has  nothing  to  do  with  the 
respiratory  sounds  at  all,  but  with  the  movements  between  the  lung 
and  the  chest.  Along  with  these  distinctions  must  be  taken  the 
correlative  evidence  as  to  whether  the  affection  be  one  of  the  lung 
or  of  the  pleura. 

c.  Crumpling  Sound. — It  most  nearly  resembles  the  crumpling 
together  of  tissue-paper;  it  is  heard  most  frequently  at  the  apex 
of  a  tuberculous  lung.  Believed  by  some  to  be  caused  by  the 
stretching  of  old  bands  of  lymph,  its  rationale  is  not  well  under- 
stood, and  its  value  is  not  great. 

d.  Creaking:  a  very  similar  sound  heard  on  deep  inspiration, 
when  the  air  first  begins  to  penetrate  a  previously  carnified  lung. 
It  has  no  interest  but  as  a  matter  of  curiosity  after  the  subsidence 
of  an  attack  of  pleurisy.  Not  unlike  to  this  is  the  creaking  pro- 
duced by  old  bands  of  lymph  in  the  lower  region  of  the  thorax, 
or  the  rubbing  together  of  roughened  portions  of  pleura  over  tu- 
bercular deposit. 

No  attempt  has  been  made  to  give  detailed  descriptions  of  these 
sounds,  because  they  can  only  be  learned  by  experience:  good  ex- 
amples of  each  should  be  sought  out,  and  carefully  listened  to, 
before  making  any  attempt  to  discriminate  them  in  obscure  cases. 

Division  I. — The  Clavicular  Region. 

§  1.  With  marked  dulness  on  one  side. 

a.  When  that  dulness  is  due  to  interstitial  deposit  we  may  have 
any  of  the  interrupted  sounds,  from  fine  crepitation  to  gurgling  and 
metallic  noises.  In  the  greater  number  of  cases,  interstitial  depo- 
sit at  the  apex  is  tubercular,  and  any  superadded  sound  serves 
only  to  show  the  particular  stage  of  the  disease;  but  when  its 
character  is  that  of  fine  crepitation,  when  the  breath-sound  has  a 
loud,  diffuse,  blowing  character,  and  the  voice  a  brassy  resonance, 
we  must  look  to  the  general  symptoms  to  see  whether  we  have  not 
to  deal  with  pneumonia:  clicking  and  squeaking  sounds,  with  sup- 
pressed or  blowing  breathing,  ajid  loud  vocal  resonance,  exist  from 
the  commencement  of  tubercular  softening;  but  with  the  marked 
dulness  now  under  consideration  we  are  more  likely  to  meet  with 
abundant  coarse,  moist  sounds  and  gurgling,  indicating  the  existence 
of  cavities.     The  character  of  the  breathing  may  scarcely  be  dis- 


218     AUSCULTATION — SUPERADDED  SOUNDS. 

tinguishablc,  because  it  is  thus  superseded,  but,  when  heard,  it  is 
harsh  and  blowing,  and  the  voice  is  always  loud.  When  the  super- 
added sound  has  a  metallic  character,  the  cavity  must  be  of  some 
size,  and  then  the  breath-sound  will  have  something  of  amphoric 
blowing,  provided  the  fluid  which  causes  the  bubbling  does  not 
oppose  the  free  ingress  of  air  into  the  cavity:  the  voice-sound  be- 
comes painfully  loud  under  such  circumstances.  Friction-sound 
may  accompany  both  forms  of  interstitial  deposit,  but  in  phthisis  it 
is  generally  peculiarly  creaking. 

B.  With  fluid  in  the  pleura.  The  entire  absence  of  superadded 
sound,  when  the  breathing  is  blowing,  and  the  voice  ringing,  is  of 
itself  a  very  important  point  in  diagnosis,  naturally  suggesting  the 
absence  of  deposit  in  the  lung,  and  leading  to  an  examination  of  its 
lower  and  back  parts.  Friction-sound  is  sometimes  heard  just  under 
the  clavicle,  but  more  commonly,  when  audible,  it  is  to  be  found 
somewhat  lower  down. 

c.  In  the  case  of  deep-seated  tumour,  while  the  breathing  is 
weak,  and  the  voice  probably  unchanged,  there  are  also  generally 
no  superadded  sounds;  at  least,  there  are  none  which  belong  to  it 
as  a  tumour,  and  those  in  the  lung  are  only  the  result  of  bronchial 
irritation:  if  it  be  an  aneurism,  there  will  be  others  connected  with 
the  circulation. 

§  2.  With  marked  resonance  on  one  side. 

A.  When  the  cause  of  this  is  the  presence  of  air  in  the  pleura, 
we  shall  have  our  diagnosis  greatly  confirmed  by  the  absence  of 
gurgling  or  metallic  noises  in  the  clavicular  region;  this  fact,  even 
when  the  metallic  tinkling  or  plashing  are  not  heard  behind,  assists 
in  distinguishing  the  case  from  one  in  which  a  large  cavity  presents 
characters  of  breath  and  voice-sound,  which  equally  deserves  the 
name  "  amphoric." 

b.  When  the  resonance  is  due  to  emphysema,  we  find  that  if 
severe  bronchitis  exist,  moist  sounds  are  audible  in  various  parts  of 
the  chest,  but  rarely  jander  the  clavicle :  with  any  degree  whatever 
of  bronchitis,  sonorous  and  sibilant  sounds  are  heard  there;  with  no 
bronchitis,  emphysema  gives  rise  to  no  superadded  sound. 

§  3.  When  the  dulness  is  not  so  marked. 

A.  In  cases  of  consolidation  of  the  lung  from  pneumonia  the  dul- 
ness is  generally  distinct;  but  though  this  sign  be  wanting,  the 
existence  of  fine  crepitation  with  whiffing  breathing,  and  brassy 
voice,  is  sufficient  to  cause  further  inquiry.  The  consolidation  is 
more  commonly  tubercular;  crepitation  of  a  coarser  kind,  with 
prolonged  expiration  and  diffuse  exaggerated  voice-sound,  accom- 
panies the  rapid  development  of  tuberculosis;  a  certain  amount  of 
chronic  pneumonia  is  probably  coincident  with  it  in  these  circum- 
stances, but  the  crepitation  is  not  so  fine,  the  breathing  is  not  whiff- 
ing, and  the  voice  is  not   brassy,  as  they  are  in  the  simple  in- 


THE  CLAVICULAR  REGION.  219 

flamniation  of  the  upper  lobe.  In  the  more  ordinary  development 
of  tubercles  fine  moist  sounds  often  occur  early  with  some  suppres- 
sion of  the  breathing,  but  with  increase  of  the  voice-sound;  when, 
towards  the  end  of  the  first  stage,  the  breathing  becomes  louder  and 
more  blowing,  clicking  or  squeaking  sounds  are  heard;  the  coarsest 
sounds  are  only  found  with  decided  dulness. 

Sonorous  sounds,  of  a  local  character,  sometimes  exist  along  with 
the  slighter  dulness  and  exaggerated  voice  of  early  phthisis  ;  they 
greatly  obscure  the  character  of  the  breath-sound;  and  in  con- 
trasting such  a  case  with  the  next,  it  is  of  the  utmost  importance 
to  observe  that  they  are  heard  on  that  side  which  is  relatively  the 
least  resonant.  Friction  and  creaking  are  both  occasionally  heard; 
the  former  coexists  with  either  form  of  consolidation,  the  latter 
always  with  tubercles:  crumpling  sound  is  generally  regarded  as  a 
very  certain  token  of  tubercular  deposit;  but  to  give  force  to  either 
of  these  signs,  the  breath  and  voice-sounds  should  also  be  conform- 
able to  such  an  hypothesis. 

b.  When  the  lung,  over  which  dulness  is  observed,  happens  to  be 
healthy,  the  other  being  emphysematous,  the  absence  of  any  super- 
added sound  on  the  duller  side,  and  the  existence  of  sonorous  sounds 
on  the  other,  are  important  aids  to  diagnosis;  but  the  latter  are 
only  audible  when  there  is  also  bronchitis.  They  are  not  entirely 
limited  to  the  clavicular  region  when  emphysema  is  present ;  and 
this  circumstance  may  be  of  use  in  judging  of  an  obscure  case, 
when  a  dilated  bronchus  produces  auscultatory  phenomena,  resem- 
bling those  of  an  empty  cavity;  moist  sounds  may  be  heard  with 
very  severe  bronchitis,  but  they  are  never  limited  to  the  apex,  and 
are  generally  audible  there  only  at  the  very  end  of  the  expiration. 

§  4.  No  difference  being  detected  in  percussion  resonance. 

a.  If  the  lungs  be  healthy  at  their  apices,  there  will  be  no  super- 
added sound.  When  very  extensive  bronchitis  exists,  both  moist 
and  sonorous  sounds  may  be  audible,  but  especially  the  latter:  if 
either  be  heard  at  one  apex  only,  while  posteriorly  the  superadded 
sound,  of  whatever  character,  prevails  to  about  the  same  extent  in 
both,  or  if  heard  at  either  apex  after  it  has  ceased  in  other  parts  of 
the  chest,  we  have  reason  to  suspect  at  least  a  tendency  to  phthisis, 
if  not  the  actual  presence  of  tubercle. 

b.  When  both  sides  of  the  chest  equally  indicate  increased  re- 
sonance on  percussion,  in  the  clavicular  region,  a  similar  condition 
is  sure  to  be  found  in  the  rest  of  the  chest.  It  very  generally 
happens  that  a  patient  applying  for  relief  in  such  circumstances  is 
at  the  time  also  suffering  from  bronchitis,  and  sonorous,  or  sibilant, 
or  even  moist  sounds,  are  to  be  heard  on  both  sides ;  and  then  their 
value  in  the  clavicular  region  is  chiefly  negative,  that  they  are 
heard  less  distinctly  there  than  elsewhere. 

c.  When  both  sides  of  the  chest  seem  equally  deficient  in  reso- 
nance, and  superadded  sounds  heard  in  the  clavicular  region  may 
also  be  detected  elsewhere,  they  will  consist  of  the  varieties  of  moist 


220      AUSCULTATION  —  SUPERADDED  SOUNDS. 

sounds  indicating  bronchitis,  or  very  generally  distributed  tuber- 
cular disease.  The  diagnosis  between  these  states  depends  so  much 
upon  the  contrast  between  the  upper  and  lower  portions  of  the 
lung,  that  their  consideration  must  be  postponed  for  the  present. 
When  the  superadded  sounds  are  confined  to  the  apex,  there  must 
be  in  reality  a  difference  in  percussion,  and  the  case  belongs  to  the 
next  subdivision. 

d.  Some  difference  on  percussion  exists  between  the  two  clavi- 
cular regions,  but  the  ear  fails  in  detecting  it.  To  the  student  this 
class  is  necessarily  a  larger  one  than  to  the  experienced  auscul- 
tator:  it  is  one  which  requires  more  than  any  other  the  exercise  of 
careful  discrimination  in  pronouncing  a  judgment,  and  it  is  import- 
ant, because  to  it  belong  the  instances  of  incipient  disease.  In  no 
class  of  cases  is  superadded  sound  of  more  value  in  forming  a  diag- 
nosis, provided  it  be  taken  in  connexion  with  the  alteration  of  the 
breath  and  voice-sounds.  Moist  sounds,  especially  those  which  have 
a  squeaking  or  clicking  character  when  found  along  with  jerking 
or  wavy  breathing,  or  prolonged  expiration  and  increased  vocal 
resonance,  indicate  most  certainly  the  presence  of  tubercular  de- 
posit, which  perhaps  never  affects  both  lungs  equally.  Coarse  moist 
sounds,  or  any  thing  approaching  to  gurgling,  can  scarcely  exist 
without  very  decided  dulness.  Very  fine  moist  sounds  approach  so 
near  to  crepitation  that  they  are  apt  to  be  mistaken  for  it:  if  dul- 
ness be  not  pronounced,  it  is  scarcely  possible  that  such  a  pheno- 
menon should  find  its  explanation  in  the  existence  of  pneumonia; 
a  more  probable  solution  is  that  capillary  bronchitis  has  been  set 
up  by  the  presence  of  tubercle.  Sonorous  or  sibilant  sounds,  when 
only  heard  at  one  apex,  are  also  evidence  of  local  bronchitis;  and 
whether  the  prolonged  sonorous  expiration  be  due  to  the  distention 
of  the  tissue  by  emphysema,  or  its  consolidation  by  tubercle,  is  a 
question  that  must  be  solved  by  the  relative  characters  of  the  breath 
and  voice-sounds  detailed  in  the  previous  chapter.  It  is  one  of  vast 
importance  in  diagnosis,  which  the  character  of  the  superadded 
sound  alone  cannot  decide,  and,  in  fact,  any  preconceived  ideas  of 
the  association  of  sonorous  sound  with  emphysema  may  very  pos- 
sibly lead  us  into  error.  A  creaking  or  friction-sound,  with  ex- 
aggeration of  the  voice  and  prolonged  expiration,  and  still  more 
decidedly,  a  crumpling  sound  at  either  apex,  are  of  much  value  in 
determining  early  tubercular  deposit  before  dulness  on  percussion 
becomes  very  perceptible.  The  presence  of  any  strictly  local 
morbid  sound  at  either  apex,  as  it  points  out  the  certainty  of  struc- 
tural change  there,  comes  to  have  immense  significance  when  other 
symptoms  indicate  the  possibility  of  tubercular  disease,  and  still 
more,  when  the  other  indications  of  percussion  and  auscultation  give 
countenance  to  the  idea  of  consolidation  at  the  apex,  where  the  lo- 
cal sound  is  heard. 

Of  the  cases  included  in  |  1,  with  marked  dulness  on  one  side,  it  is  to  be  re- 
marked that  superadded  sound,  when  it  is  of  the  interrupted  kind,  generally  proves 
that  the  change  in  density  is  due  to  interstitial  deposit:  its  fineness  or  coarse- 


THE    CLAVICULAR    REGION.  "  221 

ness  being  determined  by  the  size  of  the  tubes  or  spaces  in  wbieb  it  is  formed,  and 
the  character  of  the  exudation  by  which  it  is  caused.  When  dulness  is  marked, 
and  the  sound  fine,  it  may  be  pretty  confidently  assumed  that  the  condition  is  one 
of  hepatization,  either  with  or  without  tubercle ;  because  miliary  tubercles  would 
not  account  for  the  dulness  when  existing  only  to  such  an  extent  as  to  produce 
irritation  and  exudation  in  the  small  tubes  and  vesicles.  When  the  sound  is 
coarser,  and  consequently  formed  in  the  larger  tubes,  or  in  a  number  of  small 
cavities,  the  general  symptoms  and  history  must  determine  whether  we  have  to  do 
with  the  second  stage  of  pneumonia  or  with  phthisis;  the  latter  being  the  ordi- 
nary, the  former  a  very  unusual  cause.  When  large  bubbling  sounds  are  heard, 
we  are  sure  that  considerable  hollow  spaces  exist,  which  can  only  be  the  result  of 
tubercular  cavities,  or  of  the  much  rarer  inflammatory  disorganization  of  lung- 
tissue  which  is  always  accompanied  by  fetor  of  the  breath  and  sputa. 

The  continuous  sounds  are  seldom  heard  with  marked  dulness.  Friction  is  oc- 
casionally met  with  under  the  clavicle  when  the  dulness  is  caused  by  pleurisy,  but 
is  more  commonly  absent.  Sonorous  sound,  as  indicating  a  minor  degree  of  irri- 
tation of  bronchial  tubes,  not  extending  to  their  minute  ramifications,  might  be 
taken  as  confirmatory  evidence  that  the  dulness  was  caused  by  a  tumour. 

Vi  hen  resonance  is  excessive  on  one  side  (§  2,)  the  only  sound  which  can  be  of 
much  value  in  the  clavicular  region  is  the  sonorous:  by  its  presence  the  movement 
of  the  air  in  the  large  tubes  becomes  appreciable,  when  in  consequence  of  the  in- 
terposition of  emphysematous  lung,  in  which  the  air  is  all  but  stagnant,  no  breath- 
sound  at  all  would  be  heard  on  the  resonant  side.  Moist  sounds,  too,  may  some- 
times be  detected  on  the  resonant  side  when  the  bronchitis  is  severe,  but  these 
rather  belong  to  the  next  section. 

Iu  I  3  we  find  the  very  important  coutrast  between  partial  consolidation,  which 
is  generally  tubercular,  and  partial  emphysema.  The  very  fine  sound  of  irritation 
of  the  smallest  tubes  which  sometimes  accompanies  miliary  tubercle,  comes  very 
close  upon  the  crepitation  of  pneumonia;  sometimes,  too,  the  tubercular  deposit 
produces  a  real  pneumonia  of  slight  extent,  with  genuine  crepitation :  such  cases 
must  be  regarded  from  a  general  point  of  view,  which  includes  all  the  signs  and 
symptoms,  or  else  an  error  in  diagnosis  is  very  likely  to  be  made;  and  while  ad- 
mitting the  high  probability  that  the  consolidation  has  a  tubercular  origin,  we  must 
still  not  forget  the  possibility  of  simple  pneumonia. 

The  clicking  and  squeaking  sounds  of  softening  tubercle  are  very  decisive  when 
the  difference  in  percussion  resonance  on  the  two  sides  is  not  very  great;  and 
equally  valuable  is  the  sonorous  sound  of  bronchitis  with  emphysema:  the  one 
heard  on  the  duller  and  the  other  on  the  more  resonant  side.  But  sometimes  the 
several  explosions  or  bubbles  are  more  numerous,  and  assume  the  form  of  moist 
sounds,  and  these,  as  well  as  the  sonorous,  may  be  heard  either  on  the  duller  or 
on  the  more  resonant  side.  It  may  happen,  too,  that  the  student,  while  recog- 
nising a  difference,  is  mistaken  in  regard  to  the  relative  resonance  of  the  percus- 
sion stroke,  and  his  interpretation  of  the  cause  of  the  sounds,  is  utterly  wrong :  they 
mean,  perhaps,  only  the  presence  of  local  bronchitis,  but  they  do  not  show  why  it 
exists.  Error  in  such  cases  is  best  guarded  against  by  a  careful  consideration  of 
the  indications  derived  from  the  rest  of  the  chest;  if  no  moist  sounds  be  heard 
elsewhere,  or  if  no  evidence  of  emphysema  be  obtained  from  other  parts  of  the 
same  lung,  there  will  be  a  strong  presumption  in  favour  of  the  difference  in  per- 
cussion sound  being  due  to  tubercle:  their  general  distribution  must  be  considered 
subsequently.  It  need  only  be  added  that  the  presence  of  some  obstruction  in  the 
bronchial  tubes  which  gives  rise  to  superadded  sound,  is  very  apt  to  interfere  with 
the  indications  of  consolidation  so  far  as  the  breath-sound  is  concerned,  thus  de- 
priving us  of  one  of  the  elements  on  which,  in  the  former  chapter,  stress  was  laid 
as  a  means  of  coming  to  a  correct  judgment  iu  the  matter. 

Creaking  and  crumpling  sounds  are  less  frequently  met  with  in  the  cases 
referred  to  in  this  section  than  in  the  following  one;  but  as  they  decidedly  belong 
to  those  in  which  some  form  of  consolidation  has  occurred,  they  at  least  serve  to 
determine  the  question  of  percussion  dulness,  and  to  give  great  preponderance  to 
an  hypothesis  of  tubercle  as  its  local  cause. 

Iu  §  4  we  meet  with  the  cases  most  important  to  the  physician,  most  puzzling 
to  the  learner — the  first  stages  of  phthisis;  with  the  exception  of  a  few  instances 


222  'AUSCULTATION  —  SUPERADDED   SOUNDS. 

in  which  tubercular  Boftening  has  occurred  in  the  lower  lobes,  there  arc  none  con- 
nected  with  auscultation  in  which  it  is  so  difficult  to  come  to  a  decided  opinion. 

It  is  true  that  the  patient  cannot  know  whether  we  be  right  or  wrong,  and  that  it 

is  a  soft  course  to  give  a  rather  unfavourable  prognosis  in  all  cases  of  doubt  :  it  is 
true  that  this  course  is  pursued  by  many  of  the  most  popular  ami  most  successful 
practitioners;  but  it  is  also  true  that  this  is  the  course  of  quackery  and  imposture, 
ami  I  believe  that  no  earnest  student  will  be  satisfied  with  it,  and  that  no  ri 
minded  physician  (eels  quite  eomf'urtable  in  practising  the  little  deception  which 
such  a  method  implies. 

Here  it  must  be  admitted  that  superadded  sounds  are  sometimes  extremely 
valuable,  because  when  we  cannot  find  any  thing  wrong  elsewhere,  they 
the  existence  of  local  disease,  and  that  local  disease  may  be  tubercular.  The 
crumpling  sound,  when  heard,  is,  like  the  wavy  or  jerking  breath-sound,  that 
which  is  most  constantly  associated  with  tubercular  deposit.  Creaking  only  proves 
the  previous  existence  of  local  pleurisy,  which  very  frequently  is  set  up  by,  and, 
perhaps,  sometimes  ends  in,  tubercle.  The  fine  moist  sounds  and  the  sonorous 
sounds  referring  only  to  bronchial  irritation,  derive  their  whole  value  from  being 
the  exponents  of  local  action,  whether  they  be  heard  at  the  apex  only,  from  the 
first,  or  linger  there  when  they  have  ceased  to  be  heard  elsewhere. 

Division  II. — The  Posterior  and  Lateral  Regions. 

§  1.  When  there  is  marked  dulness  on  one  side. 

A.  In  simple  serous  effusion  the  absence  of  superadded  sound 
confirms  the  diagnosis,  proving  that  there  is  no  affection  of  the 
lung:  when  fibrin  is  also  effused,  friction  may  occasionally  be 
heard,  but  not  always.  The  point  at  which  it  is  most  frequently 
detected  is  near  the  axilla,  and  towards  the  front  of  the  chest:  and 
this  is  the  necessary  result  of  the  circumstance,  that  the  lung 
floats  upon  fluid,  which  cannot  alter  in  volume  during  respiration; 
consequently  its  free  edge  at  the  point  furthest  from  its  attachments 
is  that  which  will  most  readily  partake  of  the  movement  of  the 
fluid  as  it  rises  and  falls  with  the  decreased  and  increased  capacity 
of  the  chest  in  breathing. 

b.  When  changes  exist  in  the  interior  of  the  lung  along  with  the 
effusion  of  fluid. 

a.  We  find,  in  certain  cases,  no  superadded  sound  at  all  at  the 
base ;  higher  up,  coarse  crepitation ;  and  still  higher,  perhaps  to- 
wards the  front  of  the  chest,  or  under  the  axilla,  fine  crepitation, 
but  its  existence  depends  a  good  deal  upon  the  stage  of  the  disease. 

b.  In  other  cases  there  are  throughout  very  abundant  moist 
sounds,  diminishing  in  intensity  and  in  degree  of  coarseness  to- 
wards the  upper  and  front  parts  of  the  chest. 

These  two  conditions  are  very  dissimilar,  and  are  to  be  recognised 
by  the  different  character  of  the  voice  and  breath-sounds;  but 
they  are  still  more  marked  by  general  symptoms,  to  which  we  shall 
subsequently  refer:  the  one  is  pleuro-pneumonia,  the  other  pulmo- 
nary oedema,  with  passive  effusion  into  the  pleura. 

C.  When  the  fluid  begins  to  be  absorbed  after  pleuritic  effusion 
with  no  change  in  lung-structure,  a  crumpling  sound  is  heard,  on 
deep  inspiration,  analogous  to  that  observed  at  the  apex  in  some 
cases  of  tubercular  deposit.  It  is  an  auscultatory  curiosity  rather 
than  a  phenomenon  of  any  real  practical  value. 


THE  POSTERIOR  AND  LATERAL  REGIONS.      223 

§  2.  "With  marked  resonance  on  one  side. 

a.  When  pneumo-thorax  is  accompanied,  as  it  very  soon  is,  by 
effusion  in  the  pleura,  two  sounds  may  be  produed  -which  are  very 
diagnostic ;  the  one  a  plash,  if  the  patient  be  swayed  somewhat 
quickly  from  side  to  side,  technically  called  succussion,  which  ex- 
actly corresponds  to  the  shaking  of  any  liquid  in  a  half-empty  jar: 
the  other,  a  dropping  of  the  fluid  in  which  the  shrunken  lung  has 
been  bathed,  while  the  patient  remained  in  the  horizontal  posture; 
it  falls  in  successive  drops  from  its  lower  border  upon  the  surface 
of  the  fluid,  when  he  sits  up,  with  a  peculiar  ring,  which  is  denomi- 
nated metallic  tinkling.  These  phenomena  are  neither  of  them 
constant;  and  it  is  to  be  noted  that,  by  various  authors,  the  term 
metallic  tinkling  is  often  applied  to  any  interrupted  sound  which 
has  a  metallic  resonance. 

b.  In  emphysema  it  is  necessary,  as  already  mentioned,  for  the 
production  of  superadded  sounds,  that  bronchitis  be  present.  If 
moist  sounds  be  the  result,  they  are  louder  and  more  distinct  in 
general  bronchitis  on  the  non-resonant  side,  and  never  exist  to  any 
great  extent  in  a  very  emphysematous  lung:  when  found  only  in 
the  dilated  lung,  they  are  generally  also  few,  and  coarse,  heard  per- 
haps only  towards  the  end  of  expiration,  and  very  often  super- 
seding all  breath-sound  whatsoever.  The  sonorous  sounds,  on  the 
contrary,  are  more  audible  on  the  resonant  side :  a  prolonged  sono- 
rous expiration,  with  excessive  resonance,  is  nearly  certain  evidence 
of  emphysema. 

§  3.  When  the  difference  on  percussion  is  less  marked,  especially 
in  regard  to  resistance. 

A.   Consolidation  existing  on  the  duller  side: 

a.  The  coincidence  of  fine  crepitation  with  loud  blowing  or  whif- 
fing breathing,  and  exaggeration  of  voice,  is  very  characteristic  of 
pneumonia:  it  is  usually  local,  and  perhaps  shades  off  into  a  coarser 
sound;  it  is  generally  found  in  the  lower  lobe,  and  seldom  rises 
above  the  middle  of  the  chest. 

b.  When  the  dulness  is  more  extensive,  the  blowing  character  of 
the  breathing  less  peculiar,  and  the  crepitation  of  a  coarser  kind, 
especially  when  this  is  audible  over  the  upper  part  of  the  chest,  we 
may  suspect  that  the  consolidation  is  tubercular.  The  hypothesis 
is  confirmed  if  we  find  that  the  greatest  amount  of  crepitation  and 
the  loudest  breath-sound  are  heard  above,  and  that  both  equally 
diminish  as  we  descend,  though  occasionally  fine  crepitation  may 
be  heard  at  the  base.  Such  are  the  indications  of  acute  general 
tuberculosis  of  one  lung;  and  though  there  be  generally  such  differ- 
ences, on  auscultation,  as  are  quite  sufficient  to  denote  that  it  is  not 
pneumonia,  still  we  must  chiefly  look  to  other  circumstances  for 
correct  diagnosis,  because  there  is,  in  reality,  often  a  certain  de- 
gree of  chronic  pneumonia  present  at  the  same  time.  The  condi- 
tion of  the  patient  is  very  different  from  what  it  could  possibly  be 


224  AUSCULTATION  —  SUPERADDED    SOUNDS. 

if  there  were  the  same  extent  of  sthenic  inflammation:  and  the 
opposite  lung  very  generally  gives  evidence  of  the  development  of 
tubercles  at  its  apex.  As  soon  as  clicking  or  squeaking  sounds  at 
the  apex  take  the  place  of  crepitation,  the  apparent  obscurity  of 
the  case  is  removed. 

c.  Moist  sounds  may  be  heard  very  extensively  in  one  lung, 
which  is  the  seat  of  a  certain  amount  of  dulness,  from  the  breaking 
up  of  tubercular  deposit:  when  limited  to  the  lower  lobe  very  simi- 
lar phenomena  are  developed  by  the  suppurative  stage  of  pneumo- 
nia: the  moist  sounds  are  closely  analogous,  and  the  exaggeration 
of  the  voice  and  blowing  breathing  of  tubercular  cavities  there  do 
not  differ  from  what  is  ordinarily  heard  in  pneumonia.  The  deter- 
mination must  rest  chiefly  on  the  history,  either  of  long  ailment  or 
of  a  recent  acute  attack,  the  symptoms  of  which  have  been  neces- 
sarily severe  when  it  has  terminated  in  suppuration;  or  we  may 
obtain  evidence  of  pyaemia,  with  its  secondary  abscesses;  the  dis- 
eases which  afford  an  explanation  of  the  condition  referred  to,  are 
much  more  frequently  acute  than  chronic. 

d.  In  the  commencement  of  pleurisy,  slight  dulness  is  often 
accompanied  by  friction  before  fluid  is  effused.  Occasionally,  the 
exudation  is  wholly  fibrinous,  and  the  friction-sound  so  intense,  as 
to  resemble  crepitation. 

e.  If  the  evidence  of  consolidation  be  limited  to  the  upper  part 
of  the  chest,  the  same  rules  are  applicable  as  those  already  detailed 
in  the  previous  Division;  with  this  difference  only,  that  partial  dul- 
ness over  the  scapula  corresponds  to  marked  dulness  in  the  clavi- 
cular region.  When  the  superadded  sounds  are  found  in  both 
places  they  generally  tend  mutually  to  elucidate  each  other. 

B.  When  the  difference  in  percussion  is  caused  by  excess  of 
resonance  on  one  side,  the  absence  of  any  morbid  sounds  on  the 
duller  side,  and  their  presence  on  the  more  resonant  one,  would 
decide  that  the  case  was  one  of  emphysema. 

When  moist  sounds  are  to  be  heard  on  both  sides,  they  will 
probably  be  most  abundant  on  the  duller  one;  and  then  the  ques- 
tion must  arise  whether  this  be  not  the  seat  of  disease.  Assuming 
that  the  condition  be  one  only  affecting  the  lower  and  back  part  of 
the  chest,  we  have  to  consider  the  phenomena  connected  with  the 
breath  and  voice-sounds  as  indicating  dilatation  or  consolidation, 
especially  observing  on  which  side  they  deviate  most  from  those 
heard  a  little  higher  up ;  we  have  also  to  consider  the  characters  of 
the  moist  sounds  themselves,  whether  large  and  coarse  on  the  duller 
side,  as  they  would  be  in  the  softening  of  tubercle  and  in  suppura- 
tion of  the  lung,  or  whether,  on  the  contrary,  while  finer  and  more 
numerous  on  that  side,  they  are  only  found  as  a  few  coarse  bubbles, 
where  the  greater  resonance  is  observed,  the  air  moving  in  the  large 
tubes  while  it  is  stagnant  in  the  vesicles. 

Prolonged  sonorous  expiration,  so  constantly  heard  in  emphysema, 
would  probably  decide  at  once  that  the  resonant  side  was  that  on 


THE    POSTERIOR    AND    LATERAL    REGIONS.  225 

which  the  greatest  amount  of  disease  existed:  and  it  is  to  be 
remembered  that  such  evidence  may  often  be  obtained  in  the  clavi- 
cular region,  when  the  lung  is  emphysematous  at  its  lower  part,  and 
the  accompanying  bronchitis  is  of  such  a  character  that  nothing  but 
moist  sounds  can  be  heard  behind. 

c.  The  hypothesis  of  the  existence  of  a  tumour  deeply-seated 
would  derive  great  confirmation  from  the  absence  of  any  superadded 
sound. 

§  4.  When  no  difference  is  perceived  on  percussion. 
a.  The  percussion  being  natural. 

a.  The  absence  of  superadded  sound  proves  the  lungs  to  be 
healthy,  and  taken  in  conjunction  with  the  same  evidence  in  front, 
leads  us  to  look  elsewhere  for  the  cause  of  any  cough  that  may  be 
complained  of. 

b.  Both  sonorous  and  moist  sounds  are  to  be  heard  in  cases  of 
bronchitis,  the  former  usually  in  the  early  stage  of  an  acute  attack, 
or  where  the  disease  is  subsiding,  the  latter  being  its  more  ordinary 
manifestation,  and  being  usually  most  distinct  at  the  lowest  part  of 
the  lung.  When  moist  sounds  are  very  fine,  and  limited  to  one 
side,  the  affection  has  been  often  mistaken  for  pneumonia:  we  must 
carefully  ascertain  whether  the  localization  can  be  accounted  for  by 
consolidation,  of  which  evidence  may  be  found  in  altered  breath 
and  voice-sounds.  If  this  suspicion  be  negatived,  we  are  justified 
in  believing  that  the  case  is  one  of  simple  bronchitis.  It  is  much 
more  usual  to  find  moist  sounds  on  both  sides;  and  it  is  my  belief 
that  when  the  percussion  is  really  natural,  healthy  breathing  will 
always  be  found  at  the  upper  part  of  the  chest:  in  recent  cases 
probably  accompanied  by  some  sonorous  sounds  from  the  scantiness 
of  the  secretion;  in  chronic  cases,  sometimes  of  rather  a  harsh 
character  from  loss  of  elasticity  in  the  air-tubes.  When  the  breath- 
ing is  otherwise  altered  at  the  upper  part,  some  further  change  has 
taken  place  in  the  lung,  and  there  is  in  reality  either  increased 
resonance  or  dulness  on  percussion.  Sonorous  sounds  at  the  com- 
mencement of  the  attack  are  more  frequently  limited  to  one  side 
than  moist  sounds. 

B.  The  resonance  is  unusually  great  on  both  sides.  This  may 
vary  very  greatly  in  amount,  and  when  bronchitis  is  present, 
emphysema  gives  rise  to  all  sorts  of  moist  and  sonorous  sounds. 
When  the  latter  predominate,  the  diagnosis  is  plain  enough :  with 
the  former,  if  the  excess  of  resonance  be  small,  the  fact  that  moist 
sounds  are  heard  above  as  well  as  below  may  lead  to  the  suspicion 
that  the  case  is  one  of  very  generally  disseminated  tubercle;  this 
is  especially  to  be  remembered  in  the  emphysema  of  early  life. 
The  doubt  is  best  solved  by  a  comparison  with  the  clavicular  region, 
considering  whether  the  sounds  heard  there  would  be  best  explained 
by  the  hypothesis  of  general  emphysema  or  early  tubercular  deposit. 
Then,  again,  the  moist  sounds  of  early  phthisis  are  usually  fine, 
15 


226  AUSCULTATION — SUPERADDED    SOUNDS. 

those  of  emphysema  are  essentially  coarse,  ami  bronchial  effusion 
tends  to  accumulate  in  the  lower  or  most  dependent  part  of  the  chest. 

C.  Both  sides  may  be  equally  dull. 

it.  When  double  pneumonia  or  double  pleurisy  is  its  cause,  the 
extent  of  the  disorder  and  the  severity  of  the  general  symptoms 
are  generally  such  as  to  leave  no  doubt  on  the  mind  of  the  observer: 
the  signs  enumerated  in  §  1  are  then  found  equally  on  both  sides. 
It  is  highly  probable,  if  the  dulness  be  but  slight,  and  the  other 
signs  obscure,  that  any  sound  which  might  be  taken  for  crepitation 
is  in  reality  only  a  form  of  fine  moist  sound. 

h.  Moist  sounds  limited  to  the  base,  while  higher  up  the  breath- 
ing is  not  otherwise  modified,  except  in  being  rather  harsh,  are  very 
common  in  chronic  bronchitis,  with  some  degree  of  induration  or 
senile  atrophy.  The  very  same  indications,  however,  may  be 
present  when  tubercle  is  limited  to  the  lower  lobes,  and  it  is  just 
possible  that  such  might  be  their  true  interpretation;  but  the  pos- 
sibility is  a  rare  one,  because  in  general  the  alterations  of  sounds 
are  much  more  extensive  when  tubercular  disease  attacks  the  lower 
and  back  parts  of  the  lung. 

When  moist  sounds  are  heard  on  both  sides  throughout  the  whole  of  the  poste- 
rior region,  with  some  degree  of  dulness,  they  must  be  dependent  on  one  of  the 
following  conditions: — oedema,  engorgement,  induration  with  atrophy,  or  tubercu- 
losis. The  diagnosis  of  oedema  of  the  lungs  does  not  rest  so  much  on  any  peculi- 
arity of  the  physical  signs,  as  on  the  circumstance  of  our  being  able  to  discover 
some  present  obstruction  to  the  circulation,  such  as  produces  oedema  in  other  or- 
gans, especially  disease  of  the  heart  or  kidneys.  Secondarily,  it  would  derive  con- 
firmation from  the  expectoration  being  watery  in  place  of  puriform. 

Engorgement,  again,  depends  either  upon  obstruction  to  the  circulation  through 
the  pulmonic  veins,  or  upon  gravitation  of  blood  in  fever,  &c,  when  the  patient  is 
confined  to  bed.  Superadded  sounds  are  always  present,  which  partake  of  the 
character  of  crepitation,  or  fine  moist  sounds,  and  these  have  no  distinctive  marks. 
That  they  are  not  the  consequence  of  genuine  pneumonia,  we  only  know  from 
their  extent,  while  the  evidence  of  much  consolidation  is  wanting :  that  they  are 
not  caused  by  bronchitis  must  be  proved  by  a  consideration  of  the  relative  seventy 
of  the  symptoms. 

Tuberculosis  of  the  lower  lobes  can  scarcely  be  distinguished  from  induration, 
because  in  both  there  are  usually  present  the  signs  of  general  bronchitis.  Per- 
haps on  more  careful  percussion  we  may  be  able  to  detect  some  difference  in  re- 
sonance between  the  two  sides  in  this  form  of  phthisis;  perhaps,  too,  clicking  or 
squeaking  sounds  maybe  heard;  if  cavities  have  been  formed,  the  voice-sound 
may  be  locally  increased  at  those  spots,  or  generally  louder  at  the  base  than  at  the 
middle  of  the  lung;  information  may  also  be  gathered  from  observing  that  pro- 
longed expiration  or  vocal  resonance  is  more  distinct  on  one  side  than  the  other, 
especially  when  this  occurs  under  the  axilla  at  points  furthest  removed  from  the 
root  of  the  lungs  and  the  large  tubes.  But  all  these  evidences  may  fail,  and  we 
turn  to  the  clavicular  region,  and  there  perhaps  we  find  proof  of  more  distinct  con- 
solidation on  one  side  than  the  other,  and  we  are  satisfied  that  the  disease  is  tuber- 
cular; on  the  contrary,  we  may  find  no  great  difference  on  percussion,  each  ap- 
pearing somewhat  duil;  auscultation  may  indeed  reveal  blowing  expiration,  and 
coarse  moist  sounds  nearly  allied  to  gurgling  on  one  side,  while  the  breathing  is 
only  harsh  on  the  other,  and  yet  this  may  be  only  caused  by  a  dilated  bronchus 
along  with  the  induration,  the  apparent  dulness  being  due  to  loss  of  elasticity  of 
the  ribs.  It  must  be  confessed  that  these  cases  give  rise  to  very  great  difficulties 
in  diagnosis:  the   constitutional  symptoms,  however,   very  generally  point  more 


THE  POSTERIOR  AND  LATERAL  REGIONS.      227 

distinctly  to  one  form  of  disease  than  the  other,  and  if  we  follow  this  suggestion 
in  a  careful  analysis  of  each  of  the  signs  just  enumerated,  we  shall  probably  come 
to  a  correct  conclusion.  Certainly  the  most  trustworthy  evidence  of  tubercular 
disease  at  the  posterior  part  of  the  chest  is  derived  from  the  coincidence  of  signs 
in  the  clavicular  region;  fallacy  there  (e.  g.,  a  dilated  bronchus  mistaken  for  a  ca- 
viry)  only  arises  from  taking  one  sign  as  sufficient  to  prove  the  existence  of  tu- 
bercle. Sound  principles  demand  that  when  we  assign  to  blowing  breathing,  or 
gurgling  sounds  this  cause,  we  should  also  have  distinct  evidence  of  very  advanced 
consolidation,  because  tubercular  matter  is  not  evacuated  until  the  separate 
masses  have  been  closely  aggregated  together. 

r  These  circumstances  have  been  gone  into  with  some  minuteness,  because  the 
cases  are  very  apt  to  be  misunderstood :  the  moist  sounds  passing  from  fine  to 
coarse,  as  we  descend,  is  just  what  we  expect  to  meet  with  in  bronchitis,  and  the 
mind  is  very  readily  satisfied  with  the  explanation  of  all  the  constitutional  symp- 
toms which  this  disease  affords  when  present  in  its  chronic  form,  which  we  know 
is  very  capable  of  simulating  phthisis;  the  important  point  is  overlooked  that 
phthisis  may  simulate  bronchitis  :  to  guard  against  such  an  error  demands  close 
scrutiny  and  careful  reasoning,  for  it  must  be  remembered  that  the  prognosis  in 
the  two  disorders  is  widely  different. 

d.  The  difference  on  percussion  may  be  unobserved  because  of 
the  thickness  of  the  walls  of  the  chest. 

a.  Commencing  pneumonia  in  one  lung  may  be  indicated  by  fine 
crepitation  with  exaggeration  of  voice,  or  there  may  be  only  a  few 
moist  sounds  from  irritation  of  the  bronchial  tubes,  or  even  this 
may  be  wanting,  and  nothing  but  exaggeration  of  the  voice  be 
found ;  these  differences  merely  depending  upon  the  distance  from 
the  surface  at  which  the  fibrinous  effusion  is  taking  place,  the  over- 
lying lung  tissue  being  resonant  and  but  little  implicated  in  the 
disease.  Vocal  resonance,  therefore,  taken  along  with  general 
symptoms,  occasionally  becomes  a  valuable  distinguishing  sign 
between  pneumonia  and  bronchitis  of  one  lung,  which  no  doubt  has 
been  often  mistaken  for  it.  Friction  in  the  very  early  stage  of 
pleurisy,  before  dulness  can  be  detected,  sometimes  indicates  the 
form  which  the  inflammation  is  about  to  take,  for  undoubtedly  the 
constitutional  symptoms  are  very  often  pronounced  before  the 
physical  signs  give  us  any  very  definite  information. 

b.  Dulness  at  the  apex  posteriorly  is  very  apt  to  be  overlooked. 
The  restriction  of  moist  sounds  to  the  apex  is  a  very  important 
sign,  because  of  the  natural  tendency  of  the  fluid  in  the  bronchial 
tubes  to  gravitate  to  the  base  of  the  lungs.  All  the  superadded 
sounds  mentioned,  as  occasionally  heard  in  the  clavicular  region, 
when  dulness  is  only  slightly  marked  (Div.  I.,  §  3,)  may  be  found 
over  the  scapula  when  no  difference  on  percussion  can  be  detected 
there ;  and  in  the  supra-spinal  fossa  the  crumpling  sound  is  more 
frequently  met  with  than  any  where  else. 

c.  When  the  ordinary  signs  of  bronchitis  prevail  throughout  one 
lung,  and  are  limited  to  the  upper  part  of  the  other,  we  have  great 
reason  to  suspect  that  the  disease  has  a  tubercular  origin,  even 
when  we  cannot  make  out  any  sign  of  consolidation  at  all. 

In  proportion  as  the  thickness  of  the  walls  of  the  chest  interferes  with  the  evi- 
dences of  change  of  structure  derived  from  alterations  iu  breath  and  voice-sounds 


223      AUSCULTATION — SUPERADDED  SOUNDS. 

am!  nance,  so  do  the  superadded  sounds  acquire  importance.     The 

eluded  under  \  1  are  therefore  less  dependent  for  their  diagnosis  on  the 
-  than  those  in  which  the  percussion  Bound  is  less  distinct; 
but  they  may  be  of  so  .  as  when,  for  example,  with  disease  of  the  kidney,  we 

arc  anxious  to  know  whether  effusion  into  the  pleura  be  merely  passive,  or  the  re- 
of  inter-current  pleurisy;   the  existence  of  friction  would  prove  the  | 
;np!i.     Still  the  right  discrimination  of  all  the  cases  mentioned  in  this 
depends  more  upon  the  correct  interpretation  of  other  signs :  whiffing  breath-sound, 
for  instance,  is  much  more  valuable  than  crepitation. 

In  $  2  we  meet  with  two  very  important  sounds, — succussion  and  metallic 
tinkling.  The  first  of  these  cannot  exist  under  any  other  circumstances  than 
when  air  and  fluid  are  present  together  in  the  pleura  :  the  second,  although  liable 
■  mistaken  for  other  sounds,  is  also,  when  pure,  very  distinct  evidence  of  the 
same  fact.  But  we  must  be  able  to  assert  the  existence  of  pneumo-thorax  when 
neither  are  heard,  and  we  know  that  the  effusion  of  fluid  is  a  necessary  conse- 
quence of  the  presence  of  air.  It  is  unnecessary  to  explain  why  these  sounds  are 
sometimes  absent;  it  is  enough  to  be  prepared  for  such  an  occurrence.  It  has 
happened  to  careless  observers  to  mistake  the  gurgling  sounds  in  the  stomach  lor 
succussion;  and  by  the  best  authorities  the  name  of  metallic  tinkling  is  used  when 
there  is  no  pneumo-thorax:  it  is  well  to  remember  that  the  sound  is  merely  that 
of  fluid  dropping  in  a  partially  filled  cavity  of  some  size,  whether  that  be  in  the 
lung  or  in  the  pleura.  There  is  not  any  chance  of  a  careful  observer  mistaking 
emphysema  for  pneumo-thorax. 

The  coincidence  of  fine  crepitation  with  the  other  signs  of  pneumonia,  as  men- 
tioned in  \  3,  gives  great  certainty  to  the  diagnosis;  but  this  sign  has  been  more 
than  once  alluded  to  as  a  very  common  source  of  fallacy.  Cases  of  tuberculosis 
in  which  crepitation  at  the  back  of  the  chest  is  very  distinct  are  rare ;  but  they 
are  to  be  borne  in  mind,  especially  when  the  history  does  not  correspond  with  the 
:istion  which  this  sound  gives  of  the  existence  of  pneumonia.  Tubercular  de- 
t  limited  to  the  base,  or  more  advanced  there  than  at  the  apex,  is  that  condi- 
tion which  causes  the  greatest  difficulty  in  diagnosis  with  reference  to  the  poste- 
rior region:  such  cases  may  be  mistaken  for  pneumonia,  but  are  more  commonly 
confounded  with  bronchitis,  as  explained  in  §  4. 

There  is  less  chance  of  error  when  one  lung  is  slightly  emphysematous  at  its 
lower  part,  than  when  the  same  condition  exists  at  the  apex.  If  the  sounds  of 
bronchitis  be  limited  to  the  resonant  side,  no  mistake  can  be  made,  whether  the 
ditference  on  percussion  be  rightly  or  wrongly  interpreted;  if  they  be  heard  on 
both  sides,  although  more  distinct  on  the  duller  one,  the  suspicion  of  consolidation 
there  is  not  so  apt  to  mislead  as  it  is  in  the  clavicular  region:  the  possible  vari- 
•  are  detailed  in  the  preceding  pages  chiefly  in  order  that  the  student  may  be 
able  to  give  to  himself  a  consistent  explanation  of  what  he  hears. 

The  cases  of  real  difficulty  are  enumerated  in  \  4,  and  though  perhaps  enough 
has  been  there  stated  to  show  the  grounds  upon  which  diagnosis  is  to  be  made,  a 
recapitulation  in  a  less  formal  method  may  serve  to  make  them  more  intelligible. 
We  may  at  once  exclude  those  in  which  some  faint  stethoscopie  indication  ekes 
out  general  symptoms,  and  shows  that  pleurisy  or  pneumonia  is  impending,  or  is 
actually  present  in  minor  degree,  or  is  deep  seated.  Auscultation  can  do  no  more 
than  lend  a  feeble  aid,  and  no  great  reliauce  is  to  be  placed  upon  it.  We  may  also 
exclude  those  in  which  only  imperfect  information  is  derived  from  percussion,  be- 
cause the  walls  are  too  thick  and  unequal  {e.g.  in  the  scapular  region)  to  produce 
definite  results,  while  the  other  auscultatory  phenomena  are  well  marked  and  dis- 
tinct. The  cases  to  which  we  now  refer  are  those  in  which  the  sounds  of  bron- 
chitis are  taken  for  something  else,  or  those  dependent  on  other  causes  are  sup- 
posed to  indicate  its  presence. 

The  sounds  produced  by  bronchitis  include  two  very  distinct  classes — the  so- 
norous and  moist  sounds:  the  former  are  not  apt  to  cause  mistakes;  and  the  only 
point  to  be  remembered,  is  that  when  confined  to  one  part  of  the  chest,  there  is 
probably  some  cause  for  their  localization,  which  must  be  sought  for  in  consolida- 
tion, or  dilatation,  or  may  be  more  vaguely  traced  out  in  a  history  of  previous  in- 
flammation of  the  lung;  and  thus,  while  explicitly  pointing  to  bronchitis,  they  may 


THE  POSTERIOR  AND  LATERAL  REGIONS.      229 

be  the  means  of  detecting  other  and  more  permanent  disease.  Moist  sounds,  again, 
vary  very  much  in  character ;  and  the  range  of  those  which  may  be  caused  by 
bronchitis  and  nothing  more,  is  a  very  wide  one  :  it  is  true  in  a  general  sense,  that 
very  fine  sounds,  even  when  not  quite  what  may  be  called  crepitation,  are  most 
probably  excited  by  fibrinous  or  tubercular  deposit,  and  that  very  coarse  or  large 
bubbles  are  only  heard  when  there  is  a  cavity;  but  these  limits  cannot  be  strictly 
defined.  One  leading  characteristic  of  the  bronchial  exudation  is  its  tendency  to 
accumulate  in  the  lower  part  of  the  chest,  and  therefore  it  is  there  that  we  seek  for 
it;  and  in  a  large  proportion  of  cases  moist  sounds,  heard  there  only,  are  distinc- 
tive of  bronchitis.  The  exceptions  are  so  few,  that  if  heard  equally  on  both  sides, 
except  there  be  something  incongruous  in  the  history  of  the  case — hemoptysis, 
quick  pulse,  &c. — it  does  not  demand  any  very  close  investigation:  it  is  only  when 
they  are  confined  to  one  side  that  we  have  to  inquire  whether  there  be  not  some 
consolidation  or  dilatation  of  the  lung-tissue  existing  at  the  same  time;  and  when 
consolidation  is  found,  the  probabilities  are  very  greatly  in  favour  of  past  or  pre- 
sent inflammation — very  much  against  tubercle. 

When  the  superadded  sounds  are  not  limited  to  the  base,  there  may  be  found  in 
the  clavicular  region  or  over  the  scapula  sounds  which  closely  resemble  crepita- 
tion ;  but  we  may  at  once  dismiss  the  idea  that  the  whole  of  them  can  be  caused 
by  pneumonia,  unless  the  constitutional  disturbance  be  very  great  indeed,  and  we 
are  reduced  to  the  hypothesis  of  disseminated  tubercle  or  of  bronchitis:  we  have 
the  same  hypothesis  to  deal  with  when  the  sounds  at  the  apex  are  either  coarser 
or  sonorous.  If  the  deposits  of  tubercular  matter  be  very  wide  apart,  they  may 
not  produce  any  definite  signs  of  consolidation — generally  there  is  a  difference  be- 
tween the  two  apices,  but  not  invariably :  the  more  nearly  the  sounds  at  the  apex 
approach  to  crepitation,  the  more  distinct  the  evidence  will  be. 

The  cases  are  naturally  divided  by  their  history  into  the  acute  and  chronic ; 
those  of  recent  date,  with  simply  mucous  expectoration  or  mixed  niucilaginous- 
looking  sputa;  and  those  of  long  standing,  in  which  the  secretion  is  distinctly  puru- 
lent, or  muco-pus.  In  recent  cases  the  mode  of  incursion  very  often  indicates  the 
character  of  the  disease,  and  is  really  much  more  trustworthy  than  the  physical 
signs:  in  childhood  the  sounds  may  be  clicking  or  squeaking,  such  as  in  adults  we 
seldom  meet  with  but  in  phthisis,  and  yet  the  case  may  be  simply  bronchitis;  it  is 
at  this  age,  too,  that  we  most  frequently  find  the  equally  disseminated  tubercular 
deposit,  which  fails  in  giving  evidence  of  consolidation.  The  true  nature  of  such 
cases  can  only  be  determined  by  their  history  and  general  symptoms.  Sonorous 
sounds  at  the  apex  are  less  likely  than  any  other  variety  to  have  a  tubercular 
source  when  moist  sounds  exist  at  the  lower  part  of  the  chest:  in  adults,  when  tu- 
bercles are  present,  the  sound,  of  whatever  character,  is  generally  as  distinct  in 
front  as  at  the  back  of  the  chest,  and  very  probably  more  so  on  one  side  than  on 
the  other. 

In  chronic  cases  the  history  is  often  so  similar,  whether  there  be  tubercle  or  not, 
that  less  aid  is  derived  from  this  source;  still,  we  may  have  a  report  of  hasmopty- 
sis,  or  suspicion  may  be  aroused  by  the  extreme  rapidity  of  the  pulse,  the  fine  thin 
skin  or  clubbed  nails  of  phthisis;  and  so  great  is  the  importance  of  such  correla- 
tive symptoms,  that  the  stethoscopist  may  be  wrong,  and  the  man  who  never  prac- 
tises auscultation,  right,  in  the  interpretation  of  tubercular  disease  of  the  lower 
lobes:  all  the  physical  signs  are  readily  explained  by  the  hypothesis  of  bronchitis, 
and  the  general  symptoms  are  attributed  to  the  same  cause. 

Then,  on  the  other  hand,  a  more  common  error  is  to  be  guarded  against,  that 
differences  of  sound  at  the  apices  necessarily  indicate  tubercles:  rigidity  and  dila- 
tation of  tubes  is  so  frequent  in  chronic  bronchitis,  producing  a  certain  amount  of 
blowing  breathing,  and  giving  a  degree  of  coarseness  to  the  moist  sounds  in  one 
part  of  the  lungs,  while  a  slight  amount  of  emphysema,  or  the  closure  of  some 
tube  with  mucus,  causes  a  suppression  of  all  sound  in  another,  that  it  is  not  diffi- 
cult to  account,  in  a  general  way,  for  changes  in  breath-sound  and  varieties  of 
moist  sound  met  wdth  when  there  is  no  tubercle;  but  they  are  apt  to  mislead  the 
inexperienced. 

The  difficulty  of  ascertaining  the  exact  condition  of  the  lower  lobes,  so  far  as 
tbe  breath-sound  is  concerned,  is  very  often  increased  by  the  closure  of  tubes  just 


230  AUSCULTATION  —  SUPERADDED    SOUNDS. 

alluded  to;  and  when  the  secretion  is  very  abundant  or  much  inspissated,  no  sound 
may  reach  the  ear  over  a  large  portion  of  the  posterior  region,  except  a  few  large 
coarse  bubbles. 

Summary. 

In  reviewing  the  facts  which  superadded  sounds  really  teach, 
we  find,  first,  that  their  presence  is  a  direct  indication  that  some- 
thing is  wrong,  even  when  the  comparison  of  breath  and  voice-sound 
with  percussion  resonance  fails  in  pointing  out  that  there  is  any 
change  of  density  in  the  part;  secondly,  that  in  such  circumstances 
the  sound  is  probably  due  to  bronchitis;  thirdly,  that  when  its  cha- 
racter is  quite  local,  we  have  reason  to  suspect  that  there  is  some 
localizing  cause,  but  there  is  nothing  in  the  sound  itself  which  can 
warrant  us  in  pronouncing  decidedly  upon  the  nature  of  that  cause ; 
fourthly,  that  when  combined  with  other  physical  signs  they  rather 
tend  to  show  the  stage  of  the  disease  than  its  real  character.  When 
the  student  has  been  well  trained  in  the  principles  of  diagnosis, 
he  may  after  a  time  pronounce  Avith  comparative  certainty  on  the 
condition  of  a  patient  from  the  simple  evidence  of  superadded  sounds 
in  a  large  number  of  cases,  especially  when  they  are  heard  in  the 
posterior  and  lateral  regions:  such  a  proceeding,  however,  at  all 
times  liable  to  error,  ought  to  be  carefully  avoided  by  a  learner,  and 
even  persons  of  great  experience  fall  into  mistakes  when  trusting  to 
superadded  sounds  in  the  clavicular  region,  where  their  indications 
must  be  regarded  as  more  uncertain.  It  is  of  great  importance 
that  this  principle  be  kept  steadily  in  view;  the  stethoscope,  and 
medical  diagnosis  altogether,  are  constantly  brought  into  discredit 
by  conclusions  regarding  the  state  of  the  lungs  being  based  on  the 
evidence  which  these  sounds  afford,  to  the  exclusion,  not  only  of  ge- 
neral symptoms,  but  even  of  the  other  physical  signs,  which  are  far 
more  trustworthy  in  judging  of  change  of  structure.  The  presence 
of  some  superadded  sound  is,  indeed,  readily  detected,  and  affords 
at  once  conclusive  evidence  that  there  is  something  wrong,  vrhile  the 
comparative  estimate  of  changes  in  breath  and  voice-sound  and  in 
percussion  resonance  requires  careful  examination  and  logical  rea- 
soning to  ensure  correctness ;  and  we  are  too  prone  to  adopt  the 
easier  and  shorter  method:  but  this  very  facility  in  the  one  case  is 
apt  to  lead  to  hasty  generalizations  and  false  deductions,  which 
are  more  likely  to  be  guarded  against  by  the  caution  and  accuracy 
required  in  the  other. 

The  interrupted  sounds  for  the  most  part  show  that  there  is  some 
obstruction  to  the  entrance  or  exit  of  air,  which  is  overcome  in  a  suc- 
cession of  jerks  or  explosions,  varying  in  magnitude  and  frequency 
from  the  finest  of  crepitation  to  the  coarsest  of  gurgling  sounds: 
and,  with  certain  qualifications,  its  fineness  or  coarseness  is  a  mea- 
sure of  the  size  of  the  tube  or  space  in  which  the  sound  is  formed. 
But  if  the  cause  be  one  of  general  operation,  the  obstruction  in 
the  larger  tubes  interferes  with  the  entrance  of  air  into  the  smaller, 
and  hence  in  simple  bronchitis  the  sounds  are  seldom  of  the  finer 


SUMMARY.  231 

kind;  whereas  in  pneumonia  and  tuberculosis  the  irritation  is  limit- 
ed to  the  smallest  tubes,  and  the  finer  sounds  are  developed:  and 
this  remark  will  be  found  true  of  the  moist  sounds  heard  in  each 
disease,  even  if  the  hypothesis  should  be  subsequently  verified  that 
true  crepitation  is  produced  by  a  wholly  different  mechanism,  and 
is  absolutely  as  well  as  relatively  a  dry  sound.  The  interval  occur- 
ring between  the  explosions,  when  they  are  few  and  coarse,  or 
squeaking,  varies  chiefly  with  the  relative  viscidity  of  the  fluid: 
bubbles  of  air  passing  through  pure  pus  must  of  necessity  be  much 
larger  than  those  passing  through  simple  serum.  The  metallic  tim- 
bre which  interrupted  sounds  sometimes  present,  is  only  produced 
by  echo  in  a  large  space,  which  contains  little  fluid;  it  is  alike  pre- 
sent when  the  noise  is  caused  by  the  bursting  of  a  bubble  or  the 
falling  of  a  drop :  the  metallic  bubbling  is  the  commoner  circum- 
stance in  a  large  cavity,  the  metallic  dropping  in  the  pleura  itself, 
but  distinct  dropping  does  also  occur  in  large  cavities. 

The  continuous  sounds  have  no  character  in  common  beyond  that 
which  their  name  implies.  Sonorous  sound  teaches  that  the  air  is 
thrown  into  vibration  by  some  minor  obstruction  to  its  passage ; 
there  may  be  some  plug"  of  mucus  which,  itself  vibrating  like  the 
reed  of  a  musical  instrument,  produces  a  corresponding  sound  in  the 
air,  and  converts  a  bronchus  into  a  hautboy ;  or  there  may  become 
constriction  of  the  tube  which  causes  the  air  to  pass  with  a  hissing 
noise.  It  is  supposed  that  the  graver  sounds  are  always  produced 
in  the  larger,  and  the  shriller  tones  in  the  smaller  tubes.  Friction 
sound  is  rather  a  curiosity  than  one  which  is  readily  available  in 
diagnosis ;  pleurisy  can  be  very  well  ascertained  without  it,  and  in  the 
cases  in  which  it  might  be  expected  to  be  of  most  value,  when  fibrin 
is  poured  out  without  serum,  it  is  commonly  so  rough  and  coarse 
that  it  resembles  crepitation  rather  than  ordinary  friction.  Crump- 
lino-  and  creaking  sounds  indicate  some  hinderance  to  the  expansion 
of  the  lung,  and  are  therefore  only  of  value  when  other  abnormal 
sounds  at  the  apex  are  wanting,  or  when  at  the  base  we  find  diffi- 
culty in  explaining  the  meaning  of  dulness. 

No  mistake  is  more  frequently  made  in  the  interpretation  of  su- 
peradded sound  than  the  assumption  that  when  heard  at  the  apex  it 
is  a  certain  indication  of  tubercle.  The  probabilities  are,  undoubt- 
edly, very  greatly  in  favour  of  such  a  conclusion ;  but  it  is  precisely 
in  the  rare  cases  which  are  not  tubercular  that  skill  in  correct  dia- 
gnosis is  most  valuable  in  regard  to  treatment,  and  where  its  exercise 
requires  the  most  careful  consideration  of  all  the  circumstances. 
It  were  far  better  for  their  patients  that  medical  men  never  took  a 
stethoscope  into  their  hands,  and  trusted  solely  to  general  indica- 
tions, than  that  they  should  stop  short  of  the  knowledge  necessary 
to  enable  them  to  discriminate  such  cases. 


232 


CIIArTER  XX. 

DISEASES   OF   THE   RESPIRATORY   ORGANS. 

§  1,  Laryngitis — Acute  and  Chronic — (Edema  of  the  Glottis — to 
be  distinguished  from  Pressure  on  the  Trachea — §  2,  Tracheitis 
or  Croup — Crowing  Inspiration — §  3,  Pneumonia — its  History 
and  Symptoms — its  Auscultatory  Phenomena — Inflammation  of 
the  upper  Lobe — Abscess — Gangrene — Complications — §  4,  Pleu- 
risy— its  Eatly  Stage — its  Advanced  Stage — Complication  with 
Pneumonia — Passive  Effusion — Causes  and  Complications — 
Pleurodynia — §  5,  Pneumo-thorax — its  History  and  Symptoms 
— the  Presence  of  Fluid — §  6,  Bronchitis — Acute  and  Chronic 
—  Bronchorrhoea — §  7,  Emphysema  —  its  Complication  with 
Bronchitis — §8,  Asthma — distinguished  from  Emphysema — Say 
Asthma — §  9,  Phthisis  Pulmonalis — its  History  and  Symptoms 
— Auscultatory  Phenomena — their  Rational  Exposition — §  10, 
Tumours — §  11,  Hooping  Cough — §  12,  Chest  Diseases  in  Child- 
hood. 

Haying  in  the  previous  chapters  attempted  to  analyze  the  vari- 
ous auscultatory  phenomena  which  are  to  be  met  with  in  examining 
the  chest,  let  us  now  take  into  consideration  the  diseases  to  which 
they  owe  their  origin,  in  order  that  we  may  compare  with  the  facts 
elicited  by  percussion  and  auscultation,  the  history  and  general 
symptoms,  and  ascertain  what  influence  each  of  them  ought  to  have 
upon'  any  hypothesis  which  may  be  suggested  for  their  explanation. 
In  this  chapter  will  be  included  the  subject  of  phthisis  pulmonalis, 
although  it  be  not  properly  a  local  disease,  and  claimed  a  passing 
notice  in  the  earlier  part  of  the  volume  as  one  of  the  depraved 
constitutional  states:  it  was  then  found  impossible  to  enter  on  a 
consideration  of  the  indications  which  auscultation  affords,  and  it 
has  been  thought  better  to  place  it  in  contrast  with  bronchitis,  to 
which  in  many  respects  it  bears  a  close  resemblance.  Here,  too, 
we  must  refer  to  aneurism  of  the  aorta  and  its  subdivisions  as  one 
very  common  form  of  tumour  in  the  chest,  although  diseases  of 
blood-vessels  belong  to  another  division  of  the  subject.  Hooping- 
cough  and  croup,  while  they  have  each  some  claim  to  be  regarded 
as  epidemic,  and  popular  belief  runs  strongly  in  favour  of  the  in- 
fectious character  of  the  former,  arc  yet  neither  of  them  sufficiently 
understood,  in  a  scientific  point  of  view,  to  enable  us  to  classify 
them  except  as  affections  of  the  respiratory  organs. 

§  1.  Laryngitis. — This  affection  occurs  in  two  very  distinct  forms, 
the  acute  and  the  chronic,  which  differ  from  each  other  very  greatly 


DISEASES    OF   THE    RESPIRATORY    ORGANS.  233 

in  severity,  and  even  in  character,  so  that  it  is  only  "when  some 
fresh  accession  of  inflammation  has  occurred  that  the  chronic  dis- 
order assumes  any  practical  importance. 

In  most  cases  of  acute  laryngitis  the  attention  is  at  once  arrested 
by  a  hoarse,  prolonged,  rather  laborious  inspiration,  interrupting 
the  speech  and  causing  the  patient  to  stop  to  take  breath,  while  the 
voice  is  hoarse,  or  there  is  complete  aphonia.  The  history  may 
generally  be  summed  up  in  a  few  words;  after  some  exposure  the 
patient  has  "caught  cold,"  sore  throat  being  the  prominent  symp- 
tom, and  difficulty  of  breathing  having  come  on  early.  The  sore 
throat,  the  painful  deglutition  which  usually  excites  coughing,  and 
the  hoarseness  in  the  early  stage,  are  very  important  as  indications 
of  the  serious  malady  impending,  as  well  as  valuable  guides  when 
it  is  more  completely  developed;  because  the  amount  of  redness  of 
the  fauces  bears  no  proportion  to  the  pain  and  difficulty  of  swallow- 
ing which  the  patient  complains  of.  We  are  thus  at  once  enabled 
to  exclude  common  quinsy,  which  gives  rise  to  the  same  symptoms, 
unaccompanied,  however,  by  either  hoarseness  or  dyspnoea  in  any 
marked  degree:  the  discoloration  in  laryngitis,  too,  has  generally 
a  livid  hue. 

The  progress  of  the  disease  is  very  characteristic:  at  intervals 
the  difficulty  of  inspiration  is  much  increased,  and  then  a  period  of 
comparative  quiet  probably  follows;  but  these  spasmodic  attacks 
rapidly  increase  in  frequency  and  urgency,  till  each  inspiratory 
effort  assumes  a  convulsive  character,  the  face  grows  dusky  and  is 
covered  with  clammy  perspiration,  the  shoulders  and  clavicles  are 
heaved  upwards  in  laborious  breathing,  the  larynx  moves  up  and 
down  in  a  tumultuous  manner,  and  instant  suffocation  seems  impend- 
ing; the  patient  can  scarcely  make  the  attempt  to  speak,  or  if  he 
do,  it  is  only  in  a  short,  hoarse  whisper. 

At  the  commencement  of  the  attack  there  is  usually  a  good  deal 
of  febrile  excitement,  a  hot  skin,  quick,  firm  pulse,  and  flushed 
face;  as  the  insufficient  aeration  of  the  blood  goes  on,  and  begins 
to  tell  on  the  constitution,  the  pulse  fails  in  power  and  increases 
in  rapidity,  the  skin  tends  to  coldness,  the  flush  on  the  cheek  is 
changed  to  a  dusky  tint.  All  this  bears  upon  correct  diagnosis, 
although  what  it  teaches  be  simply  that  there  is  some  obstruction 
to  the  entrance  of  air  into  the  lungs :  the  consciousness  of  the  pa- 
tient, indeed,  points  out  that  it  is  in  the  larynx ;  but  we  know  that 
any  cause  might  have  the  same  effect  upon  the  breathing,  which 
opposed  a  similar  obstacle  to  the  inflation  of  the  lung:  such  circum- 
stances, we  shall  find,  perplex  the  diagnosis  of  the  chronic  affection. 

As  in  many  other  diseases  of  the  respiratory  organs,  the  patient 
suffering  from  acute  laryngitis  usually  assumes  the  sitting  posture; 
he  cannot  lie  down  with  ease,  but  shows  more  restlessness  and 
anxiety  than  under  any  other  affection :  cough  is  never  prominent, 
perhaps  rarely  present,  for  the  patient  cannot  fill  his  lungs  suffi- 
ciently to  produce  it.     His  sensations  point  simply  to  the  larynx, 


234  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

except  that  now  and  then  there  may  be  pain  at  the  lower  end  of 
the  sternum,  caused  by  the  laboured  inspiratory  movements.  The 
evidence  derived  from  auscultation  and  percussion  is  entirely  nega- 
tive: wherever  the  stridulous  laryngeal  noise  does  not  prevent  the 
breath-sound  from  being  heard,  the  indications  are  those  of  health. 

Besides  this  form  of  laryngitis,  which  may  be  termed  the  idio- 
pathic, it  is  met  with  as  a  consequence  of  injury,  such,  for  example, 
as  the  entrance  of  an  irritant  fluid  or  gas  into  the  trachea:  it  super- 
venes, as  already  mentioned,  on  the  chronic  form:  or  it  ascends 
from  the  inflamed  trachea  of  croup,  or  descends  from  the  inflamed 
fauces  of  quinsy.  Its  association  with  croup  and.the  means  of  discri- 
minating the  two  diseases  will  come  under  our  notice  in  the  next 
section :  in  each  of  the  other  cases,  the  history  and  symptoms  are 
primarily  those  of  the  precedent  affection ;  and  a  knowledge  of  its 
existence  prepares  us  for  the  correct  interpretation  of  sudden  dys- 
pnoea, raucous  breathing,  and  symptoms  of  suffocation  when  the 
laryngitis  supervenes. 

There  is  also  what  may  be  termed  a  bastard  laryngitis  occa- 
sionally met  with,  consisting  of  oedema  of  the  glottis.  It  is  prin- 
cipally associated  with  the  sore  throat  of  erysipelas,  and  with  renal 
disease:  and  this  would  lead  to  the  belief  that  it  has  the  character 
of  low  phlegmonous  inflammation  rather  than  that  of  simple  serous 
effusion.  But  the  swelling  of  the  vocal  cords  from  this  effusion  is 
the  dangerous  circumstance,  and  that  which  brings  it  into  associa- 
tion with  laryngitis.  The  symptoms  are  less  severe,  and  the  inflam- 
matory .fever  is  absent;  the  dyspnoea,  however,  is  sometimes  equally 
urgent;  the  correct  interpretation  of  the  form  of  obstruction  is 
chiefly  inferential;  the  co-existence  of  the  other  forms  of  disease 
excludes  the  idea  of  acute  or  sthenic  inflammation ;  and  when  dis- 
ease of  the  kidney  is  present,  even  if  unknown,  there  is  generally 
external  swelling  of  the  throat,  as  well  as  internal  oedema. 

The  absence  of  auscultatory  phenomena,  indicative  of  disease  of  the  lungs,  is 
most  important  in  regard  to  treatment.  I  have  more  than  once  seen  the  operation 
of  tracheotomy  performed  without  even  a  transient  relief  to  the  sufferer;  with  in- 
deed, in  one  case,  manifest  injury,  from  the  excitement  and  alarm  it  produced. 
In  these  cases  the  diagnosis  was  based  on  insufficient  premises :  there  were,  it  is 
true,  the  sudden  invasion  after  exposure,  the  rapid  progress,  the  inflammatory 
fever,  and  the  extreme  dyspnoea,  with  discoloration  of  the  face ;  but  neither  had  there 
been  sore  throat  nor  aphonia,  and  unmistakeable  signs  in  the  lungs  showed  that  if 
the  larynx  were  implicated  it  was  only  secondarily;  postmortem  examination  re- 
vealed what  is  not  inaptly  called  broncho-pneumonia  of  the  most  extensive  kind, 
in  each  of  these  patients.  The  propriety  of  the  operation  must  entirely  rest  upon 
the  correct  interpretation  of  the  causes  which  produce  the  suffocation  which  it  is 
intended  to  relieve;  but  it  is  even  more  apt  to  be  undertaken  with  a  wrong  im- 
pression when  urgent  symptoms  supervene  in  chronic  cases,  than  when  the  dis- 
ease is  from  the  first  acute. 

Aphonia  is  a  very  good  measure  of  the  extent  of  tbe  inflammation,  or  rather  of 
its  progress,  and  of  the  effects  it  has  produced.  "When  the  hoarseness  has  passed 
rapidly  into  complete  aphonia  the  affection  is  unquestionably  a  grave  one.  Feel- 
ing an  inability  to  produce  any  laryngeal  sound,  the  patient  may  be  content  to 
speak  in  a  whisper;  but  it  is  to  be  remembered  that  this  does  not  of  necessity  im- 


LARYNGITIS.  235 

ply  the  existence  of  aphouia;  and  if  no  effort  be  made  to  produce  articulate  sound, 
we  have  at  least  the  right  to  suspect  that  the  patient  may  have  the  power  to  do  so, 
but  does  not  exercise  it.  This  is  one  of  the  common  manifestations  of  hysteria, 
but  is  not  likely  to  be  mistaken  for  acute  laryngitis;  it  is  rather  the  chronic  af- 
fection which  it  simulates;  and  along  with  the  aphonia  there  maybe  an  unnatural 
barking  cough,  which  tends  to  make  the  counterfeit  more  complete:  in  such  cir- 
cumstances tracheotomy  has  been  performed  without  the  very  slightest  necessity, 
in  consequence  of  mistaken  diagnosis.  More  commonly  hysterical  aphonia  lasts 
for  months  or  years,  the  patient  all  the  time  being  able  to  speak  aloud  if  she  but 
made  a  real  effort. 

In  chronic  laryngitis  the  disease  is  not  only  of  much  longer  dura- 
tion, but  of  much  less  severity;  and  except  when  an  acute  attack 
supervenes,  there  is  at  no  time  urgent  dyspnoea.  The  inspiratory 
act  is  sometimes  noisy,  and  more  laboured  than  natural;  but  gene- 
rally the  voice  is  much  more  affected  than  the  breathing:  it  becomes 
rough  and  harsh,  or  husky,  or  may  be  lost.  Chronic  laryngitis  is 
connected  especially  with  two  other  forms  of  disease,  the  tubercular 
and  the  syphilitic,  and  it  is  therefore  important  to  make  out  from 
the  history  and  symptoms  whether  either  of  these  cachexies  may 
exist  as  its  cause.  In  some  cases  disease  in  the  larynx  and  trachea 
has  proceeded  much  further  than  in  the  lungs,  where  only  a  few 
miliary  tubercles  exist — phthisis  laryngea  it  used  to  be  called; 
and  then  its  tubercular  nature  is  not  so  readily  made  out :  to  one 
accustomed  to  watch  all  the  indications  of  disease  there  is  something 
very  characteristic  in  the  altered  voice  of  phthisis,  caused  no  doubt 
by  the  circumstance  that  such  inflammation  of  the  glottis  tends  to 
ulceration  rather  than  to  thickening  of  the  cords.  In  the  syphilitic 
form  we  trust  more  to  the  existence  of  secondary  symptoms  of  any 
sort  than  to  the  history  of  infection,  which  the  patient  may  have 
an  object  in  denying. 

Besides  these  varieties,  chronic  laryngitis  may  be  left  after  a 
more  acute  attack  of  the  idiopathic  kind  has  passed  away;  and 
there  would  also  seem  to  be  some  tendency  to  a  recurrence  of  the 
disease  in  a  chronic  form,  after  any  exposure,  in  a  person  who  has 
once  suffered  from  the  acute  disorder.  In  other  instances  we  find 
it  associated  with  disease  of  bone  or  cartilage. 

The  general  symptoms  depend  more  upon  the  condition  of  the 
patient  in  other  respects  than  upon  the  severity  of  the  local  ailment, 
which  is  not  such  as  materially  to  affect  the  health.  There  is  fre- 
quently a  feeling  of  soreness,  or  dryness  of  throat,  with  some  diffi- 
culty in  swallowing;  occasionally  the  act  of  deglutition  excites 
cough,  which  may  end  in  retching:  in  many  cases  these  symptoms 
are  wholly  wanting.  There  is  usually  tenderness  on  pressure  over 
the  larynx ;  any  alteration  in  form,  or  any  degree  of  fulness,  would 
lead  us  to  suspect  disease  of  bone  or  cartilage.  Cough  is  very 
generally  present,  is  harsh,  and  sometimes  peculiar  in  tone;  but 
less  so,  as  a  general  rule,  than  in  affections  of  the  trachea. 

The  disease  most  liable  to  be  confounded  with  chronic  laryngitis 
is  aneurism  of  the  aorta:  any  tumour  in  the  same  situation  would 


DISEASES    OF    THE    RESPIRATORY    ORGANS. 

produce  similar  results;  but  practically  this  is  the  cause  which  most 
commonly  originates  them.  By  some  physiologists  it  has  been  as- 
sumed that  the  symptoms  are  produced  by  pressure  on  the  laryngeal 
nerves,  especially  the  recurrent;  but  no  doubt  much  is  due  to  the 
irritation  produced  by  its  actual  contact  with  the  trachea  itself. 
Tlic  only  conclusive  evidence  is  the  discovery  of  the  tumour:  a 
suspicion,  indeed,  that  the  dyspnoea  and  cough  may  not  be  the  ef- 
fect of  laryngitis,  will  probably  be  suggested  by  the  absence  of 
soreness  in  the  throat,  and  the  character  of  the  voice,  which  is  not 
absolutely  hoarse,  but  has  rather  a  cracked  sound,  and  is  wanting 
in  power;  the  sound  of  the  cough  is  not  so  rough,  but  generally 
more  harsh  and  clanging.  Such  circumstances,  however,  only 
amount  to  bare  suspicion:  more  value  may  be  attached  to  the  fact 
that  while  there  is  no  soreness  of  the  throat,  there  is  often  a  pecu- 
liar dysphagia — a  sensation  of  the  food  sticking  fast  in  the  gullet, 
which,  like  the  changes  in  breathing  and  voice,  may  be  partly  due 
to  interference  with  nerves,  partly  to  pressure  on  the  oesophagus. 

§  2.  Tracheitis,  or  Croup.  Crowing  Inspiration. — Acute  in- 
flammation of  the  entrance  of  the  air-passages  in  childhood  is  an 
affection  quite  sui  generis.  It  is  not  here  our  business  to  enter  upon 
its  pathology,  but  merely  to  point  out  that,  while  in  the  adult  the 
inflammation  is  commonly  limited  to  the  larynx,  or  at  least  derives 
all  its  importance  from  the  inflammation  attaching  itself  to  the 
opening  of  the  glottis,  in  childhood  the  trachea  is  the  chief  seat  of 
the  inflammation:  the  larynx  and  the  fauces  are  usually  involved 
secondarily  and  to  a  less  degree.  The  chief  exception  to  this  is 
found  in  the  diphtheritis  which  often  prevails  epidemically  on  the 
Continent:  it  clearly  commences  in  the  upper  part  of  the  pharynx, 
and  very  often  terminates  in  true  croup. 

In  the  history  of  the  case  we  either  find  that  the  child  has  been 
ailing  for  two  or  three  days,  with  symptoms  of  cold  attended  by 
hoarseness,  or  that  the  antecedents  have  been  so  slight  as  to  have 
escaped  notice,  and  that  the  child  has  waked  up  in  the  night  in  a 
state  of  high  fever,  with  considerable  difficulty  in  breathing.  The 
attendant  phenomena  always  indicate  very  marked  febrile  disturb- 
ance; the  skin  is  hot,  the  pulse  quick,  and  the  face  flushed,  and 
the  progress  of  the  symptoms  is* closely  analogous  to  those  already 
mentioned  in  laryngitis.  Hoarseness  is  an  indication  which  de- 
serves a  first  place  among  the  evidences  of  the  disease,  because  it 
is  one  which  so  seldom  attends  the  common  colds  of  childhood: 
next — if  considered  along  with  other  circumstances — the  peculiar 
croupy  inspiration  which  follows  a  fit  of  coughing,  and  the  brassy 
or  ringing  noise  of  the  cough  itself;  when  taken  alone,  these  signs 
have  often  led  to  mistaken  diagnosis.  As  the  disease  proceeds, 
membranous  shreds  of  lymph  may  be  coughed  up  or  expelled  by 
vomiting,  or  patches  of  lymph  may  be  seen  on  the  fauces:  this 
renders  the  diagnosis  of  the  disease  quite  certain;   but  in  some 


PNEUMONIA.  237* 

cases  no  membrane  at  all  is  found,  the  trachea  and  bronchi  are 
simply  inflamed  and  bathed  in  purulent  secretion.  Auscultation  of 
the  chest  reveals  noisy  breathing,  mixed  with  a  variety  of  clacking 
or  moist  sounds,  according  to  the  character  and  extent  of  the 
secretion. 

In  attempting  to  discriminate  between  croup  and  acute  laryngitis,  we  have  first 
the  very  broad  distinction  that  the  one  is  a  disease  of  childhood,  the  other  of  adult 
life:  a  form  of  tracheitis  is  indeed  sometimes  found  in  young  adults,  in  which 
fibrinous  exudation  lines  all  the  tubes,  even  to  their  minute  ramifications;  but  this 
is  confessedly  so  rare  that  it  may  be  left  out  of  account.  Next  we  have  the  cir- 
cumstance that,  except  when  lymph  is  visible  in  the  fauces,  there  is  no  sore  throat 
or  difficulty  in  swallowing;  and  lastly,  the  stethoscopic  signs  of  affection  of  the 
tubes,  which,  though  obscured  by  the  noisy  breathing,  are  nevertheless  capable  of 
being  discriminated.  These  indications  also  bear  upon  the  important  question  of 
tracheotomy.  Powerful  to  save  life,  when  the  larynx  only  is  involved,  it  is  gene- 
rally absolutely  useless  when  the  bronchi  are  implicated,  and  not  unattended  with 
danger:  the  absence  of  stethoscopic  evidence  of  bronchial  inflammation,  and  the 
existence  of  sore  throat,  or  lymph  on  the  fauces,  would  justify  our  entertaining  the 
proposition  if  it  ever  ought  to  be  practised  in  croup;  the  more  abundant  the  lymph 
about  the  fauces  the  less  probability  is  there  of  its  having  passed  to  any  consi- 
derable distance  along  the  trachea.  Both  affections  are  alike  liable  to  exacerba- 
tions and  remissions,  which  are  probably  of  spasmodic  character;  but  in  croup 
there  are  also  violent  fits  of  coughing,  which  are  comparatively  rare  in  laryngitis. 

Crowing  inspiration,  or  false  croup,  is  often  mistaken  for  the  true, 
especially  by  those  who  are  content  with  solitary  indications:  the 
appearance  of  impending  suffocation  is  even  greater  in  the  spas- 
modic disease,  and  the  inspiration  following  the  temporary  closure 
of  the  glottis,  from  which  it  derives  its  name,  sounds  very  similar 
to  that  following  a  fit  of  coughing  in  croup ;  but  in  other  respects 
the  diseases  differ  very  widely.  The  crowing  inspiration  rarely 
extends  beyond  the  period  of  dentition,  with  the  irritation  of  which 
it  is  closely  connected:  it  comes  on  suddenly,  without  preliminary 
catarrh,  cough,  or  hoarseness ;  it  is  not  accompanied  by  inflam- 
matory fever,  and  as  soon  as  the  paroxysm  has  passed,  the  breath- 
ing is  completely  free  from  obstruction.  In  all  these  respects  it 
stands  in  complete  antagonism  to  the  true  croup.  It  is  evidently 
a  paroxysmal  disease,  and  more  nearly  related  to  the  convulsions 
than  the  inflammations  of  childhood,  as  shown  by  spasm  of  the 
flexors  of  the  thumbs  and  great  toes,  which  is  so  frequently  observed 
during  the  attack:  it  is  especially  associated  with  disorder  of  the 
primge  viae,  inflamed  gums,  and  impetigo  capitis  leading  to  enlarged 
cervical  glands.  By  some  pathologists  enlargement  of  glands  has 
been  supposed  to  be  its  ultimate  cause ;  that  of  the  thymus  gland, 
especially,  tending  to  produce  pressure  on  the  laryngeal  nerves; 
probably  the  two  affections  only  stand  to  each  other  in  the  relation 
of  common  effects  from  the  same  cause:  imperfect  nutrition  alike 
manifesting  itself  in  convulsion,  in  cutaneous  eruption,  enlargement 
of  glands,  and  faulty  assimilation. 

§  3.  Pneumonia. — Inflammation  of  the  substance  of  the  lung 
generally  presents  itself  to  our  notice  only  in  the  acute  form; 


•  238  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

chronic  pneumonia  is  sometimes  the  accompaniment  of  rapid  tuber- 
culosis, and  as- i  1 1  only  occupy  our  attention  as  one  of  the  compli- 
cations of  that  disease.  Its  history  is,  therefore,  recent ;  nor  do 
we  find  that  the  patient  has  been  liable  to  similar  attacks  at  previous 
periods.  We  only  learn  that,  after  some  sort  of  exposure,  severe 
cold  has  been  caught:  in  its  commencement  there  may  have  been 
rigor,  or  pain  in  the  side;  but  these  phenomena  are  often  absent. 
It  is  always  attended  with  more  or  less  inflammatory  fever,  as  in- 
dicated by  the  heat  of  surface,  coated  tongue,  quick  pulse,  fee., 
occasionally  the  combination  of  increased  arterial  action  and  in- 
sufficient aeration  of  the  blood,  together  produce  a  peculiar  dusky 
flush  on  the  cheek,  which  is  very  striking.  The  breathing  is  hur- 
ried, and  in  severe  cases,  the  number  of  inspirations  in  a  given 
time  exceeds  the  normal  standard  in  a  much  higher  ratio  than  the 
acceleration  of  pulse.  The  cough  is  hard  and  dry,  especially  in  the 
earlier  stages,  the  tough  adhesive  phlegm  being  brought  np  with 
difficulty  and  presenting  very  soon  a  rusty  colour  from  an  intimate 
admixture  of  blood:  the  expectoration  is  much  more  abundant,  and 
more  distinctly  blood-tinged  when  the  type  of  the  inflammation  is 
lower  in  degree.  Pain  is  sometimes  complained  of,  from  the  pre- 
sence probably  of  a  slight  complication  of  pleurisy,  and  the  patient 
has  a  general  sense  of  illness  much  more  decidedly  than  in  bron- 
chitis for  example. 

The  distinctness  of  the  auscultatory  signs  depends  very  much 
upon  the  position  of  the  inflammation,  whether  near  the  surface  or 
deeply  seated.  It  attacks  the  lower  and  back  parts  of  the  lungs 
very  much  more  frequently  than  the  upper  and  anterior  portions, 
and  we  have,  therefore,  much  more  confidence  in  the  diagnosis 
when  observed  somewhere  behind  or  to  either  side:  the  percussion 
dulness  is  not  complete,  and  generally  not  very  extensive:  in  parts 
the  breathing  is  suppressed,  in  parts  much  exaggerated,  but  nowhere 
entirely  absent,  even  down  to  the  very  edge  of  the^ diaphragm;  the 
expiratory  sound  is  longer  in  proportion  to  the  inspiratory  than 
in  health,  and  when  much  exaggerated  it  becomes  very  loud 
and  blowing,  with  a  whiffing  metallic  or  brassy  character,  com- 
monly called  tubular  breathing.  The  voice-sound  is  increased,  and 
becomes  diffuse,  ringing,  or  metallic;  but  it  has  neither  the  sharp- 
ness of  that  produced  in  a  large  cavity,  nor  the  shakiness  of  that 
which  accompanies  the  effusion  of  fluid.  When  fine  crepitation  is 
distinctly  heard  as  accompanying  the  foregoing  phenomena,  the 
diagnosis  may  be  pronounced  with  certainty :  the  sound  is  not  heard 
over  the  whole  of  the  hepatized  portion  of  the  lung,  but  more  com- 
monly towards  its  edges,  and  sometimes  only  when  a  deep  inspiration 
is  made.  The  period  of  the  disease  during  which  really  fine  crepita- 
tion is  audible— that  form  of  it  which  consists  of  very  fine  crack- 
ling, heard  only  at  the  end  of  each  inspiration, — is  limited,  and  is 
soon  succeeded  either  by  its  almost  total  cessation,  or  by  its  gradual 
transition  through  coarse  crepitation  into  true  moist  sound.     Sono- 


PNEUMONIA.  239$ 

rous  sound  is  sometimes  heard  in  consequence  of  the  presence  of 
bronchitis:  and  not  only  does  acute  bronchitis  accompany  pneu- 
monia, but  it  may  precede  it,  and  among  the  aged  is  very  often  its 
exciting  cause.  In  such  cases  the  history  is  a  good  deal  modified, 
and  the  auscultatory  phenomena  are  not  so  distinct. 

The  condition  just  described  is  that  of  the  fully-developed  dis- 
ease ;  but  the  practitioner  may  have  to  treat  a  case  in  an  earlier 
stage,  when  the  history  is  such  as  leads  him  to  suspect  inflamma- 
tion of  the  lung,  while  yet  there  is  no  evidence  of  consolidation. 
He  only  finds  that  on  one  side  the  breathing  is  weaker  than  on  the 
other,  and  then  undoubtedly  fine  crepitation  is  among  the  surest 
and  the  earliest  indications  of  what  is  going  to  happen;  but  while 
he  fails  in  no  part  of  the  treatment  which  the  general  condition  of 
the  patient  and  the  probability  of  the  invasion  of  pneumonia  would 
indicate,  it  is  wise  to  abstain  from  a  positive  diagnosis  until  the 
signs  be  more  fully  developed,  in  order  that  he  may  not  be  misled 
in  his  judgment  of  subsequent  symptoms,  which  may  prove  the 
disease  to  be  something  else,  bronchitis  or  pleurisy  for  example. 

It  must  be  remembered,  too,  that  when  pneumonia  is  deep-seated, 
its  presence  will  scarcely  be  marked  by  any  physical  signs  at  all ; 
but  if  sufficient  regard  be  paid  to  the  whole  category  of  symptoms, 
we  may  be  contented  if  the  diagnosis  derive  confirmation  from  su- 
perficial weakness  or  deficiency  of  breathing,  with  local  exaggera- 
tion of  voice-sound,  especially  when  these  indications  are  met  with 
at  the  side  of  the  chest,  at  a  distance  from  the  large  tubes,  while 
percussion  elicits  no  dulness,  and  auscultation  detects  no  crepita- 
tion. In  either  of  these  cases  the  practitioner,  by  causing  the  pa- 
tient to  cough,  or  even  only  to  talk,  and  thus  securing  deep  inspi- 
ration, may  develop  the  absent  phenomenon  of  crepitation.  One 
form  of  pneumonia  in  particular  belongs  to  this  class ;  it  is  that 
dependent  on  secondary  suppurative  fever  with  pyaemia.  The  small 
foci  of  purulent  pneumonia  are  rarely  to  be  discovered  by  ausculta- 
tion; and  the  supervention  of  cough,  with  any  alteration  in  the 
breath-sound  on  one  side  of  the  chest,  is  enough  to  show  that 
secondary  suppuration  has  attacked  the  lung:  but  here  the  ques- 
tion of  which  organ  is  attacked  is  merged  in  the  more  important 
one  of  a  general  crasis  of  the  blood,  indicated  by  the  symptoms  of 
suppurative  fever. 

The  great  error  of  physical  diagnosis,  in  asserting  that  fine  crepitation  is  patho- 
gnomonic of  pneumonia,  has  been  already  mentioned.  It  may  be  quite  true  that 
there  is  one  form  of  it  which  is  never  heard  in  any  other  condition  of  disease 
(yet  even  this  may  be  exactly  simulated  by  coarse-friction-sound  ;)  it  may  be  also 
true  that,  if  this  form  be  clearly  and  distinctly  heard,  pneumonia  is  certainly  pre- 
sent ;  but  if  we  take  all  the  varieties  of  crepitation  into  account  which  we  do  hear 
in  true  pneumonia,  they  are  clearly  not  confined  to  it.  It  is  equally  false  to  as- 
sume that  crepitation  is  a  certain  indication  of  pneumonia,  and  that  its  absence 
proves  the  disease  to  be  of  some  other  kind. 

The  real  value  of  crepitation  is  only  as  it  conforms  or  is  opposed  to  other  signs 
of  disease ;  when  no  other  symptoms  of  pneumonia  accompany  its  presence  we 


240  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

must  seek  for  some  different  explanation  of  the  phenomenon;  its  entire  absence 

may  lead  us  to  suspect  thai  we  nave  been  wrong  in  attributing  other  symptoms  to 

pneumonia;  bul  Li  thai  evidence  be  distinct,  its  degree  of  coarsen  i  not  be 

■ded;  nay,  even  when  the  character  of  the  sound  is  entirely  altered,  and  ac- 

companies  expiration  as  well  as  inspiration,  it  still  does  not  stultify  the  diagnosis 

of  pneumonia,  but  only  shows  that  an  unusual  amount  of  serous  exudation  has 

B  fact  which  the  character  of  the  expectoration  will  probably  sutli- 

utly  ratify. 

Pneumonia  is  most  frequently  found  in  the  lower  lobes,  and  we 
consequently  place  most  reliance  upon  the  auscultatory  phenomena 
when  observed  in  that  situation ;  we  receive  their  evidence  with 
more  hesitation  when  confined  to  the  upper  lobe ;  and  when  the 
whole  lung  presents  the  same  character  of  dulness,  blowing,  breath- 
ing, and  crepitation,  we  may  be  certain  that,  unless  the  general 
symptoms  be  very  grave  indeed,  the  disease  is  partly  if  not  wholly 
tubercular. 

In  distinguishing  fibrinous  from  tubercular  deposit  in  the  upper 
lobe,  we  must  remember  that  very  fine  crepitation  is  rarely  met 
with  at  the  upper  part  of  the  lung ;  consequently,  the  more  con- 
tinuous the  sound  appears,  the  more  distinct  its  limitation  to  the 
inspiration  alone,  and  the  more  equal  its  diffusion  over  a  considera- 
ble space,  the  more  probably  is  it  caused  by  pneumonia.  We  have 
first  to  take  into  consideration  the  history  of  the  case,  the  duration 
and  general  symptoms  of  the  disease,  and  the  character  of  the 
sputa ;  and  next,  to  remember  that,  in  such  a  situation,  if  the  pa- 
renchyma be  infiltrated  with  lymph,  dulness  must  necessarily  be 
very  marked ;  the  vesicles  are  occluded,  and  the  vesicular  murmur 
will  therefore  be  annihilated;  the  tubes  remain  open,  are  inflamed 
and  indurated,  and  the  breathing  will  consequently  be  very  loud 
and  whiffing,  and  the  voice-sound  brassy,  and  much  increased  in 
intensity.  It  will  also  be  remarked  that  these  changes  are  pretty 
equally  extended  to  the  whole  lobe  of  the  lung,  and  its  margin 
pretty  clearly  defined  by  their  extent,  because  they  are  often 
more  marked  towards  its  lower  part  than  quite  at  the  apex. 

"But  not  unfrequently  pneumonia  of  the  upper  lobe  is  only  en- 
grafted on  previous  tubercular  deposit,  and  then  the  crepitation  is 
coarser,  the  breathing  less  whiffing,  the  voice  not  so  brassy ;  the  spe- 
cial signs  and  the  general  symptoms  each  approximate  to  those  of 
phthisis,  of  which  we  have  yet  to  speak  (§  9.)  One  source  of  fallacy 
is  when  loud  blowing  breathing  is  heard  in  an  empty  vomica,  and 
crepitation  exists  in  its  immediate  neighbourhood:  but  if  carefully 
examined,  clicking  or  squeaking  sounds  will  be  found  mingled  with 
the  crepitation,  which  is  always  coarse ;  the  expiration  is  more 
blowing,  and  less  whiffing ;  the  voice-sound  is  less  brassy,  and  more 
shrill;  and  careful  percussion  will  detect  a  hollowness  or  wooden 
resonance  over  one  particular  point,  which  under  certain  circum- 
stances, presents  what  is  called  the  cracked-pot  sound:  still  more, 
these  characters  are  strictly  local,  and  limited  to  the  immediate 
region  of  the  cavity:  above,  below,  and  on  either  side,  are  heard 


PNEUMONIA.  241 

the  sounds  belonging  to  tubercular   consolidation;  and,  above  all, 
the  history  and  symptoms  are  of  phthisis,  not  of  pneumonia. 

Pneumonia  sometimes  runs  on  to  the  formation  of  abscess.  Apart  from  those 
cases  which  are  due  to  secondary  suppuration,  this  is  a  very  rare  event,  and  inas- 
much as  in  its  advanced  stages  the  exudation  becomes  purulent,  while  the  physi- 
cal signs  of  complete  consolidation  around  large  tubes  differ  but  little  from  those 
of  a  cavity,  mistakes  have  often  been  made  in  the  interpretation  of  abundant  puru- 
lent expectoration,  with  loud  blowing  breath-sound  confined  to  some  particular 
spot  at  the  base  of  the  lung.  It  is  true  that  careful  auscultation  would  prove  this 
to  be  more  diffuse  than  cavernous  breathing  ought  to  be;  but  this  fact  mav  be 
overlooked:  another  consideration,  however,  forces  itself  on  our  attention;  when 
pneumonia  terminates  in  abscess,  some  poi-tion  of  the  lung  structure  becomes  dis- 
organized, and  pus  evacuated  from  an  abscess  of  this  sort  has  always  a  fetid  odour, 
and  it  is  not  safe  to  diagnose  abscess  of  the  lung  in  such  circumstances  where  this 
character  is  wanting.  This  rule  does  not  apply  to  secondary  deposits  which  pre- 
cede the  pneumonia,  gradually  enlarging  as  the  inflammation  goes  on.  Such  cases 
are  very  commonly  called  gangrene  of  the  lung;  but  while  there  is  undoubtedly 
destruction  of  some  portion  of  the  tissue,  the  primary  condition  is  suppuration,  and 
they  may  be  readily  distinguished  from  true  gangrene  by  the  appearance  of  the 
sputa:  in  the  latter  always  brown  or  blackish,  in  the  former  chiefly  purulent;  the 
odour  in  both  is  that  of  sphacelus,  which  impregnates  the  breath  of  the  unfortu- 
nate patient,  and  is  diffused  throughout  the  apartment.  Gangrene  is  a  much  more 
fatal  disease  than  fetid  abscess,  and  is  generally  not  immediately  related  to  pneu- 
monia. 

Chronic  pneumonia  seldom  exists  independent  of  tubercles:  sometimes  in  a  case 
of  long  standing,  when  the  period  of  fever  and  rusty  expectoration  has  gone  by, 
we  find  evidence  of  consolidation,  with  coarse  crepitation  and  moist  sounds  at  the 
base  of  one  lung.  In  the  absence  of  the  tubercular  diathesis  we  may  hope,  and 
if  the  patient  get  thoroughly  well,  we  may  believe,  that  it  is  a  case  of  chronic 
simple  pneumonia;  but  such  are  rare. 

Cases  sometimes  present  themselves  in  which  we  find  evidence  of  a  low  form  of 
pneumonia  coexisting  with  some  other  disease,  and  we  must  be  careful  that  the 
diagnosis  of  pneumonia,  however  clearly  made  out,  does  not  cause  us  to  overlook 
the  complication.  Fever,  for  example,  often  presents  such  a  combination,  when 
it  may  require  very  nice  diagnosis  to  say  in  how  far  the  fever  arises  from  the 
pneumonia,  or  the  pneumonia  from  the  fever.  This  is  not  merely  an  idle  specu- 
lation, because  important  practical  results  in  regard  to  treatment  depend  upon 
the  decision.  When  properly  considered,  the  treatment  of  one  or  other  disease 
will  not  be  blindly  followed;  but  the  educated  practitioner  will  ever  bear  in  mind 
the  two  very  opposite  diseases  he  has  to  treat  together,  and  modify  his  remedies 
to  meet  the  exigencies  of  the  case — especially  when  an  acute  inflammatory  disease 
supervenes  on  a  chronic  exhausting  one.  The  combination  with  pleurisy  will  be 
subsequently  referred  to;  its  chief  importance  with  regard  to  diagnosis  comes  from 
the  manner  in  which  it  modifies  the  auscultatory  phenomena :  to  its  presence  we 
must  no  doubt  ascribe  the  circumstance,  that  sometimes  the  sound  of  crepitation, 
heard  early  in  the  disease,  ceases,  and  instead  of  being  replaced  by  blowing  breath- 
ing, and  other  phenomena  of  advanced  consolidation,  the  breath-sound  itself  be- 
comes inaudible:  it  seems  impossible  that  fibrinous  deposit  beginning  near  the 
surface  should  of  itself  cause  a  stagnation  of  the  air  in  the  large  tubes,  which  can 
never  be  closed  by  such  means;  neither  is  there  any  reason  why  the  sound  of  its 
necessary  movement  should  not  be  transmitted  to  the  ear,  unless  the  lung  be 
pushed  aside  by  fluid.  The  condition  already  referred  to,  in  which  the  presence 
of  vesicular  breathing  at  the  surface  prevents  our  hearing  the  blowing  sound  of 
deep-seated  pneumonia  is  of  quite  a  different  nature. 

The  coexistence  of  delirium  is  not  to  be  regarded  as  a  separate  disease,  but  as 
one  of  the  phenomena  attending  on  severe  pneumonia.  It  is  of  much  importance 
in  treatment,  and  when  appearing  early  may  lead  to  a  suspicion  that  fever  of  the 
continued  type  exists  along  with  the  pneumonia,  but  does  not  necessarily  imply 

16 


DISEASES    OP    THE    RESPIRATORY    ORGANS. 

this  tin'  altered  character  of  the  blood  is  sufficient  to  account  for  the 

cerebral  disturbance. 

§  4.  Pleurisy. — In  its  proper  sense,  one  of  the  acute  inflamma- 
tions of  the  chest,  it  commonly  sets  in  with  pretty  smart  fever  and 
stitch  in  the  side.  We  find  from  the  history,  perhaps,  that  there 
been  some  exposure  to  cold,  and  that  the  attack  commenced 
with  rigor.  The  ordinary  symptoms  of  inflammatory  fever  are 
present,  with  considerable  dyspnoea,  manifested  in  quick,  shallow 
breathing,  with  little  movement  of  the  ribs:  the  patient  especially 
abstains  from  taking  a  deep  breath,  or  making  any  attempt  to 
cough,  because  the  friction  of  the  inflamed  surfaces,  caused  by 
either  act,  excites  or  aggravates  the  sensation  of  pain:  the  charac- 
ter of  the  pain  is  sharp  and  darting,  and  it  is  referred  to  a  spot 
just  below  the  nipple,  on  the  affected  side.  The  face  is  seldom 
flushed,  and  the  colour  is  not  dusky,  because  there  is  no  obstruc- 
tion to  the  oxygenation  of  the  blood  as  it  passes  through  the  lung. 
In  the  early  stage  the  patient  seldom  lies  on  the  affected  side,  as 
he,  does  at  a  more  advanced  period — probably  he  complains  that 
such  a  posture  increases  his  sufferings;  at  this  time,  too,  the  physi- 
cal signs  are  few  and  indistinct.  They  consist  simply  of  impaired 
movement  of  the  ribs  over  the  whole  side,  or  more  particularly  over 
that  part  where  the  inflammation  has  commenced.  The  breath- 
sound  is  more  or  less  suppressed  or  jerking,  in  consequence  of  the 
pain  attendant  on  full  and  perfect  inspiration ;  the  expiration  ap- 
pears prolonged.  This  suppression  partially  extends  to  the  healthy 
side,  and  thus  tends  to  diminish  the  contrast  between  the  two. 
The  voice-sound  is  generally  exaggerated  at  an  early  period  over 
the  seat  of  inflammatory  action.  Friction  is  sometimes  heard  very 
soon  after  the  disease  has  commenced,  and  then  there  is  always 
attendant  dulness  on  percussion.  Here  the  disease  may  stop,  and 
no  effusion  of  fluid  occur;  and  it  does  occasionally  happen,  particu- 
larly in  cachectic  states,  that  the  inflammatory  fever  proves  fatal, 
with  delirium  and  copious  effusion  of  lymph,  without  any  exuda- 
tion of  serum  at  all.  In  such  cases  the  friction-sound  may  be  very 
persistent  and  very  grating,  and  heard  over  a  large  surface,  imi- 
tating closely  the  crepitation  of  extensive  low  pneumonia.  These, 
however,  are  exceptional  cases;  the  friction  is  generally  transient, 
and  the  patient  either  recovers  rapidly,  or  the  inflammation  goes 
on  to  the  effusion  of  fluid. 

The  duration  of  the  disease,  however,  may  be  very  prolonged; 
and  when  the  case  first  comes  under  observation,  such  a  history 
must  not  exclude  the  possibility  of  pleurisy.  It  may  happen  that 
the  early  stage  is  scarcely  marked,  that  there  has  been  no  pain,  no 
febrile  disturbance,  nothing  to  denote  what  is  going  on,  till  dys- 
pnoea appears  as  the  result  of  the  pleura  having  become  full  of  se- 
rum. The  patient  may  have  had  pain  in  the  affected  side  for  weeks 
or  months  from  some  other  cause — dyspepsia  for  instance;  and  it 


PLEURISY.  243 

then  becomes  quite  impossible  to  fix  the  date  of  the  commencement 
of  pleurisy. 

In  the  further  progress  of  the  case,  dyspnoea  becomes  a  more 
constant  feature,  ordinary  breathing  is  interfered  with,  as  •well  as 
the  more  unusual  respiratory  efforts ;  pain,  if  it  have  existed,  sub- 
sides. The  face  is  apt  to  be  dusky  or  discoloured;  and  the  patient 
very  often  seeks  an  erect  posture,  inclining  to  the  affected  side. 
Dulness  on  percussion  is  very  manifest;  at  the  base  the  sound  is 
especially  dead,  inelastic,  and  resistant;  higher  up,  while  it  acquires 
some  degree  of  elasticity  the  resonance  no  where  presents  the  cha- 
racter of  health.  The  breath-sound  is  absent  at  the  base;  above  it 
is  blowing,  and.  the  expiration  prolonged.  The  only  exception  to 
this  rule  in  simple  pleurisy,  arises  from  some  part  of  the  lung  being 
tied  down  by  old  adhesion ;  but  as  it  cannot  be  so  on  all  sides 
without  its  being  so  generally  adherent  that  there  is  no  room  for 
fluid,  the  characters  enumerated  must  be  detected  somewhere,  if 
they  be  not  general.  Towards  the  upper  part  of  the  chest,  gene- 
rally about  the  lower  angle  or  spine  of  the  scapula,  the  quivering 
or  shakiness  of  the  voice-sound,  called  regophony,  is  perceptible. 
When  the  pleura  becomes  quite  full,  the  intercostal  spaces  bulge ; 
the  dulness  passes  the  median  line  in  consequence  of  the  mediasti- 
num being  pushed  over,  and  along  with  it  the  heart  is  displaced: 
this  circumstance  is  to  be  observed  earlier,  and  is  always  more 
palpable  wrhen  the  fluid  is  on  the  left  side.  The  breath-sound  is 
almost  entirely  suppressed:  now  and  then  the  sound  of  friction 
may  be  caught,  its  position  depending  on  the  amount  of  fluid,  the 
laws  of  gravitation,  and  the  circumstance  of  air  entering  at  all 
into  the  lungs,  and  leading  to  relative  change  of  position  between 
it  and  the  parietes.  After  pleurisy  has  lasted  some  time,  the  recur- 
rence of  rigor,  followed  by  copious  sweating,  generally  indicates 
the  conversion  of  the  serous  effusion  into  pus;  empyema  as  it  is 
called. 

The  pleura  and  the  subjacent  lung,  being  so  closely  connected, 
are  very  often  simultaneously  attacked  by  inflammation;  perhaps 
the  exposure  to  cold,  which  causes  the  pleurisy,  at  the  same  time 
gives  rise  to  pneumonia,  or  to  bronchitis.  In  the  latter  case  the 
superadded  sounds  due  to  bronchial  secretion  accompany  the 
changes  in  breath-sound  more  properly  belonging  to  pleurisy:  in 
other  respects  the  physical  signs  are  the  same.  But  it  is  different 
with  pneumonia:  here  the  consolidation  of  the  lung  prevents  its 
yielding  so  much  to  compression,  and  the  fluid  rises  all  around  it; 
the  upper  lobe,  which  is  not  inflamed,  yields  to  compression,  and  the 
evidences  of  pneumonia  are  confined  to  the  central  regions  of  the 
chest;  necessarily  modified  by  a  stratum  of  fluid  being  interposed, 
and  giving  rise  to  unusual  dulness.  "While  this  dulness  indicates 
pretty  plainly  the  presence  of  fluid,  the  observer  is  surprised  by 
the  sound  of  breathing  extending  so  far  down,  and  for  a  moment 
doubts  whether  there  can  be  effusion  after  all.     In  others  of  these 


HAl  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

complicated  cases  the  signs  of  pneumonia  may  have  been  detected 
early,  but  the  consolidation  may  not  have  proceeded  far,  or  may 
have  been  limited  to  the  outer  part  of  the  lung,  -which  is  then 
pushed  so  far  away  from  the  side  of  the  chest  by  effusion,  that  the 
crepitation  and  blowing-sound  cannot  reach  the  ear,  and  the  con- 
clusion may  be  arrived  at  that  very  severe  pneumonia  exists  when, 
in  truth,  it  is  very  slight.  In  all  of  these  cases  we  derive  some  in- 
struction from  the  characters  of  the  expectoration.  Simple  pleurisy 
shows  nothing  more  than  the  ordinary  secretion  of  mucus,  which  is 
brought  up  with  difficulty,  or  not  at  all ;  more  abundant  expectora- 
tion indicates  pretty  surely  the  existence  of  some  degree  of  bron- 
chitis; rusty  expectoration  most  certainly  that  of  pneumonia. 

It  is  well  to  limit  the  term  hydro-thorax  to  those  cases  of  passive  effusion  in  which 
the  existence  of  fluid  iu  the  pleura  is  only  one  form  of  local  dropsy;  not  forget- 
ting, however,  that  a  low  form  of  inflammation  of  serous  membranes  generally  is 
one  of  the  most  common  occurrences  in  dropsy  connected  with  Bright's  disease. 
Such  cases,  besides  presenting  the  ordinary  evidence  of  fluid  in  the  pleura,  are 
marked  by  the  comparative  rarity  of  true  regophony,  and  the  constant  presence 
of  the  moist  sounds  of  bronchitis,  or  rather  bronchorrhoea,  as  the  necessary  result  of 
an  cedematous  state  of  the  lung.  The  amount  of  fluid  is  never  extreme  when  there 
is  no  inflammation,  and  very  commonly  it  is  found  in  both  pleurae,  which  is  very 
uncommon  in  pleurisy. 

By  the  general  statement  that  dulness  extends  in  greater  or  less  intensity 
throughout  the  whole  side  of  the  chest  in  which  pleurisy  with  effusion  is  present, 
it  is  not  meant  to  deny  the  existence  of  a  sort  of  tympanitic  sound  at  the  apex,  to 
which  attention  has  been  called  by  some  auscultalors.  To  my  mind  the  name 
seems  misapplied,  and  is  apt  to  convey  to  students  a  wrong  notion  of  what  they 
are  likely  to  hear.  It  somewhat  approaches  to  the  "cracked  pot"  sound;  and  it 
is  important  to  remember  that  this  kind  of  wooden  hollow  resonance  may  be 
heard  when  the  only  change  in  structure  in  the  lung  is  condensation  from  -the 
pressure  of  fluid  below:  it  has  been  mistaken  for  the  resonance  of  a  cavity. 

It  may  sometimes  be  of  use  to  the  student  to  observe  whether  the  relations  of 
dulness  and  want  of  breathing  to  the  rest  of  the  chest  be  at  all  altered  by  change 
of  posture:  the  gravitation  of  the  fluid,  and  floating  of  the  lung  upon  its  surface, 
bringing  the  breath-sound  to  a  locality  where  before  it  was  absent,  would  be  strong 
confirmatory  evidence  of  pleuritic  effusion. 

In  the  early  stage  obscurity  is  chiefly  owing  to  the  circumstances  that  there  is 
no  change  of  structure,  and  that  the  only  evidence  which  a  physical  examination 
can  afford  is  suppression  of  breathing,  from  imperfect  action  of  the  lung:  but  this 
stage  cannot  last  long;  and  pain  of  some  days'  standing,  without  effusion  of 
Ivmph  or  serum,  cannot  be  pleurisy.  In  the  more  advanced  stages,  the  difficulties 
are  caused  either  by  consolidation  of  lung-structure  preventing  its  being  floated 
up  by  the  liquid,  or  old  adhesions  fixing  it  firmly  in  its  place.  It  is  impossible  to 
point  out  all  the  variations  in  auscultatory  phenomena  which  the  latter  may  pro- 
duce; but  it  is  worthy  of  remark  that  the  fact  of  a  previous  attack  ought  to  have 
been  ascertained  in  obtaining  the  history  of  the  case,  and  the  observer  prepared 
to  look  for  unusual  effects  in  making  his  examination.  "When  the  adhesions  arc 
very  extensive,  there  is  a  permanent  deficiency  of  resonance  which,  though  of  no 
it  amount  in  the  majority  of  cases,  may  yet  be  perplexing,  especially  in  chil- 
dren,  where  the  parietes  are  thin,  and  changes  of  resonance  consequently  great. 

The  most  important  feature  of  passive  effusion  is  that  it  has  occurred  during 
the  continuance  of  a  disease  which  tends  to  cause  dropsical  accumulations:  and 
probability  that  such  is  its  true  explanation  may  be  shown  by  the  presence  of 
anasarca  in  the  lower  limbs,  or  of  disease  of  the  heart  or  kidneys,  even  when 
there  is  no  dropsy  elsewhere.  On  the  other  hand,  if  hydro-thorax  be  the  first 
fact  that  is  brought  to  our  notice,  its  insidious  progress,  and  the  absence  of  pain 


PNEUMO-THORAX.  245 

or  fever  in  the  commencement,  ought  to  lead  us  to  look  further  into  the  case,  in 
order  to  ascertain  if  there  be  any  other  condition  of  disease  with  which  it  may  be 
associated.  There  is  still  greater  reason  for  such  a  suspicion,  if  the  effusion  be 
on  both  sides.  We  also  meet  with  other  rarer  causes  of  effusion,  in  pressure  on, 
or  occlusion  of  vessels;  but  in  them  hydro-thorax  is  very  subordinate. 

Still  more  constant  is  the  association  of  all  other  forms  of  disease  of  the  chest 
with  pleurisy:  pneumonia  is  perhaps  the  most  constant;  then  phthisis,  which 
especially  develops  a  local  and  asthenic  pleurisy  without  serous  exudation ;  less 
frequently  bronchitis,  which  seems  to  be  more  distinct  and  independent,  only  ac- 
knowledging the  same  cause,  and  developed  simultaneously. 

Pleurisy  is  also  met  with  as  the  result  of  accident, — fracture  of  the  ribs,  with 
local  injury  of  the  serous  membrane.  This  fact  is  one  that  ought  not  to  have 
been  passed  over  in  obtaining  the  history  of  the  case,  and  it  can  scarcely  be  so, 
because  the  patient  knows  of  the  injury  and  feels  the  pain,  while  he  knows  nothing 
of  the  pleurisy;  he  therefore  talks  of  his  accident  as  the  cause  of  his  sufferings. 
It  is  the  business  of  his  medical  attendant  to  find  out  the  pleurisy,  remembering 
that  the  signs  will  be  a  good  deal  modified  by  the  cause;  for  the  same  suppression 
of  breathing  on  the  painful  side  will  occur  as  in  pleurisy,  because  of  the  aggrava- 
tion of  the  pain  by  breathing:  but  when  the  movement  of  the  fractured  rib  is 
prevented  by  the  support  of  a  bandage,  the  breathing  is  again  at  once  in  great 
measure  restored,  if  pleurisy  have  not  supervened.  Spitting  of  blood  may  have 
attended  the  accident,  the  lung  structure  having  been  torn;  and  we  may  find 
emphysema  or  pneumo-thorax,  as  the  result,  to  complicate  the  diagnosis. 

Pleurodynia  is  sometimes  in  all  probability  only  a  very  limited 
form  of  pleurisy,  which  speedily  contracts  adhesions,  and  gives  rise 
to  no  positive  auscultatory  phenomena:  such  we  may  feel  sure  is  its 
meaning  when  it  occurs  in  a  case  of  tubercular  disease.  But  the 
name  is  more  properly  applied  to  muscular  rheumatism  affecting 
the  intercostal  and  other  respiratory  muscles:  it  occurs  as  a  sudden 
attack  of  pain  in  the  side,  which  interferes  with  the  breathing, 
catches  the  patient  in  attempting  to  cough  or  inspire  deeply,  and 
may  even  give  rise  to  the  motionless  condition  of  the  ribs  and  want 
of  breath-sound  which  have  been  spoken  of  as  accompanying  the 
early  stage  of  pleurisy.  The  diagnosis  rests  on  the  absence  of 
febrile  disturbance,  the  extent  over  which  pain  is  felt,  the  existence 
of  superficial  tenderness,  and  the  character  of  the  pain,  which  is 
rather  a  diffuse  soreness,  as  if  the  side  had  been  bruised,  than  a 
sharp  stitch,  like  that  of  pleurisy:  the  presence  of  rheumatism  in 
anjr  other  organ  would  give  great  assurance  of  its  nature,  and  this 
may  often  be  further  proved  by  its  being  excited  by  any  muscular 
movement,  such  as  raising  the  arm,  or  bending  the  body  from  side 
to  side. 

§  5.  Pneumo-thorax. — This  seems  the  most  proper  place  for 
introducing  a  few  remarks  upon  this  disease,  because  it  presents 
some  relations  to  pleurisy.  Its  history  is  necessarily  one  of  previous 
ailment:  if  the  patient  be  known  to  have  had  phthisis,  we  conclude 
that  the  air  has  made  its  way  by  ulceration  from  within  outwards; 
if  he  be  known  to  have  had  pleurisy,  we  suspect  empyema  has 
existed  with  suppuration  and  abscess  of  the  lung.  It  may  also 
occur  as  the  sequel  of  an  accident  causing  rupture  of  the  lung,  or 
of  a  natural  or  artificial  opening  through  the  parietes  for  the  exit 


240  DISEASES    OF    THE    HE  S  PI  R  ATO  11  Y    ORGANS. 

of  pus  or  scrum  from  the  pleura:  in  such  cases  the  amount  of  air 
is  commonly  less  than  •when  an  ulcerated  opening  into  the  lung 
exists.  In  cases  of  phthisis  the  event  has  probably  happened  with 
a  sensation  of  something  having  given  way  in  a  fit  of  coughing  or 
in  some  unusual  strain;  in  empyema  the  first  event  is  the  discharge 
of  a  large  quantity  of  pus  by  expectoration:  the  latter  is,  however, 
a  very  rare  occurrence.  In  either  case  there  is  excessive  dyspnoea; 
sometimes  with,  sometimes  "without  pain  on  the  affected  side:  and 
fluid,  if  not  previously  present,  is  very  soon  secreted. 

The  febrile  symptoms  are  generally  evident  enough,  but  not 
severe ;  and  they  necessarily  present  a  low  type  in  consequence  of 
the  previous  condition  of  the  patient.  His  aspect  is  generally 
expressive  of  anxiety  and  depression,  with  more  or  less  dusky  dis- 
coloration of  the  face.  He  very  commonly  seeks  a  semi-erect  pos- 
ture, inclining  to  the  side  of  the  disease;  but  not  unfrequently 
there  is  no  urgent  dyspnoea  till  an  attempt  at  movement  be  made, 
when  it  immediately  becomes  very  marked. 

The  affected  side  of  the  chest  is  rounded  and  motionless,  has  a 
loud  tympanitic  resonance,  with  a  wooden  hollowness  if  pleurisy 
exist;  and  then  there  must  also  be  dulness  at  the  base,  in  propor- 
tion to  the  amount  of  fluid.  Throughout  the  whole  of  that  side 
there  is  entire  absence  of  the  vesicular  murmur:  at  the  upper  part 
some  of  those  sounds  may  be  heard  which  accompany  consolidation, 
when  such  a  condition  has  prevented  the  lung  from  completely  col- 
lapsing. Amphoric  breathing  is  heard  more  or  less  loudly  as  we 
chance  to  listen  near  to  or  at  a  distance  from  the  opening  into  the 
lung,  or  it  may  be  suspended  by  temporary  closure  of  the  aperture: 
when  present  it  is  accompanied  by  amphoric  voice-sound,  which  is 
usually  more  general.  When  these  signs  exist,  taken  in  conjunc- 
tion with  the  history,  and  with  the  tympanitic  resonance,  pneumo- 
thorax cannot  be  mistaken  for  anything  else;  the  possible  error  of 
mistaking  a  large  cavity  for  a  case  of  this  disease  will  be  discussed 
along  with  the  evidence  of  vomicee  in  phthisis.  If  the  aperture  be 
closed,  the  stillness  throughout  the  chest  is  such  as  no  extreme  of 
emphysema  ever  simulates:  if  there  be  any  doubt,  we  observe  that 
on  the  affected  side  there  is  none  of  the  heaving  movement  of  the 
upper  ribs,  and  the  drawing  inward  of  the  lower,  so  remarkable  in 
extensive  emphysema;  while  on  the  opposite  side  there  is  no  pro- 
longed or  sonorous  expiration;  we  only  discover  exaggerated 
natural  breathing  (puerile  as  it  is  called,)  so  far  as  the  lung  is 
healthy:  and  this  is  most  evident  about  the  centre  of  the  chest, 
where  we  escape  alike  from  the  signs  of  tubercle  and  of  bronchitis 
or  partial  pleurisy  on  that  side.  But  the  history  of  the  case  ought 
to  set  us  free  from  any  doubt  between  emphysema  and  pneumo- 
thorax; and  if  the  signs  of  phthisis  be  met  with  in  the  clavicular 
region,  they  would  only  tend  to  confirm  the  diagnosis,  because 
tubercular  ulceration  is  one  of  the  causes  of  the  disease:  but  they 
are  not  often  present;  for,  unless  the  apex  be  fixed  by  adhesion,  it 


BRONCHITIS.  247 

is  certain  to  be  displaced  inwards,  and  adhesion  acts  as  a  safeguard 
against  the  escape  of  air  into  the  pleura. 

But  there  are  other  signs  which  are  still  more  easily  recognised, 
when  fluid  is  present  as  well  as  air.  In  the  erect  posture,  if  the 
lung  have  shrunk  so  that  its  base  does  not  reach  the  level  of  the 
fluid,  we  hear,  on  listening  at  the  back  of  the  chest,  when  the 
patient  first  rises  up,  a  dropping  of  the  fluid,  in  which  its  posterior 
portion  was  floating  when  the  patient  lav  on  his  back :  it  has  a 
metallic  sound,  and  is  known  as  metallic  tinkling.  At  first  the 
drops  fall  in  rapid  succession,  gradually  becoming  fewer,  until  they 
cease  altogether.  This  sound  is  very  characteristic;  and  when 
observed  along  with  the  other  signs  of  pneumo-thorax,  the' diagnosis 
amounts  to  a  certainty.  But  it  is  not  always  heard,  because  the 
lung  may  touch  the  fluid  even  when  the  patient  is  erect.  We  may 
then  move  the  upper  part  of  the  patient's  body  backwards  and  for- 
wards as  he  sits,  while  the  ear  is  applied  to  the  chest,  to  catch  the 
plashing  sound  of  succussion.  Doubt  has  been  expressed  whether 
the  stomach-sounds  might  not  be  mistaken  for  those  produced  in 
the  pleura;  but  they  can  only  be  so  by  one  who  has  never  heard 
true  succussion :  when  heard  and  recognised,  it  affords  as  perfect 
confirmation  of  the  other  signs  as  metallic  tinkling. 

Air  may  be  generated  in  the  pleura  by  decomposition  of  fluid,  or 
may  be  admitted  by  paracentesis:  in  such  cases  there  must  always 
have  been  previous  pleurisy.  The  air  rises  to  the  top,  causes  a 
local  tympanitic  sound,  and  deadens  the  sound  of  breathing,  because 
it  is  a  bad  conductor  when  interposed  between  two  solid  substances 
— the  lung  and  the  parietes.  The  fact  is  a  mere  curiosity,  and  has 
really  no  practical  bearings.  It  might  be  mistaken  for  a  cavity 
with  unusual  resonance,  and  so  might  lead  a  hasty  person  to  say 
that  there  was  phthisis  coexistent  with  pleurisy.  Such  a  diagnosis 
is  always  hazardous ;  for  what  are  supposed  to  be  the  most  common 
signs  of  phthisis  may  be  exactly  simulated  by  those  of  pleurisy 
with  accompanying  bronchitis,  while  there  is  no  tubercular  deposit 
whatever  in  the  lung.  On  careful  consideration  of  the  condition 
referred  to,  it  will  not  be  difficult  to  perceive  that  the  resonance  is 
too  great  for  any  thing  but  air  in  the  cavity  of  the  pleura,  and  that 
the  auscultatory  sounds  are  only  deficient  in  distinctness:  we  may 
also  generally  cause  this  tympanitic  resonance  to  change  its  place 
by  altering  the  position  of  the  patient. 

§  6.  Bronchitis. — The  two  forms  of  this  disease,  the  acute  and 
the  chronic,  may  be  recognised  by  their  history:  the  auscultatory 
phenomena  are  sometimes  exactly  the  same  in  each,  and  when  they 
differ,  they  derive  their  distinctive  characters  rather  from  the  quali- 
ties of  the  secretion  than  from  the  fact  that  the  membrane  is  in  a 
state  of  recent  or  of  long  standing  inflammation,  except  in  so  far 
as  dilatation  or  rigidity  of  the  tubes  has  been  produced  by  repeated 
attacks. 


248  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

In  the  acute  form  we  obtain  simply  the  history  of  cold  followed 
by  catarrh,  which  may  have  been,  in  the  first  instance,  attended  by 
a  good  deal  of  heat  of  skin  and  chilliness,  by  pain  diffused  over 
the  front  of  the  chest,  and  a  tearing,  or  painful  sense  of  tickling 
after  coughing:  there  is,  at  first,  no  expectoration;  but  the  secretion 
gradually  increases  in  amount,  generally  becomes  glairy  and  trans- 
parent for  some  days,  and  subsequently  yellowish  and  partly  opaque. 
The  cough  commonly  causes  headache  during  the  febrile  state,  and 
there  is  some  thirst  and  loss  of  appetite,  without  much  acceleration 
of  pulse. 

An  attack  of  influenza  differs  in  no  respect  from  this  form  of  bronchitis,  except 
in  the  severity  of  the  concomitant  fever;  there  is  decided  quickness  of  pulse, 
coating  of  tongue,  and  heat  of  skin,  with  more  intense  headache,  general  lassi- 
tude and  depression,  complete  loss  of  appetite,  &c.  But,  after  all,  the  two 
ases  merge  so  completely  into  each  other,  that  a  case  must  be  called  influenza 
or  bronchitis  very  often  solely  from  the  circumstance  that  the  disorder  is  or  is  not 
epidemic.  The  same  depression  will  attend  severe  bronchitis  in  a  feeble  person 
that  marks  influenza  in  the  robust;  and  hence  the  inquiry  into  the  patient's  pre- 
vious health,  unimportant  as  regards  diagnosis,  is  of  value  in  determining  on  treat- 
ment; and  although  it  be  a  most  dangerous  error  to  treat  the  nomenclature  of 
disease  in  place  of  the  patient,  the  name  of  influenza  sometimes  serves  to  remind 
us  of  depression,  and  prevent  unnecessary  depletion. 

The  chest  is  perfectly  resonant  on  percussion  so  far  as  the  bron- 
chitis is  concerned.  The  breathing  is  at  first  accompanied  by 
sonorous  sounds,  which  are  believed  to  be  graver  when  formed  in 
the  largo  tubes,  shriller  when  in  the  small:  moist  sounds  are  next 
heard ;  which  begin  by  accompanying  the  sonorous,  and  gradually 
supersede  them  altogether,  until  the  declension  of  the  disease,  when 
they  are  again  heard:  the  breathing  first  becomes  natural  at  the 
apices,  and  the  moist  sounds  linger  longest  at  the  bases:  the  voice- 
sound  remains  as  in  health.  There  may  be  some  difference  in 
degree,  but  these  phenomena  are  usually  met  with  on  both  sides 
alike  in  simple  bronchitis. 

If  the  moist  sounds  be  confined  to  one  side,  the  case  may  be  mistaken  for  pneu- 
monia, especially  when  they  are  fine  and  limited  to  the  base  of  the  lung:  the  pre- 
sence of  sonorous  sounds  would  be  sufficient  to  prevent  such  an  error;  but  when 
these  have  ceased,  the  determination  must  rest  on  the  absence  of  all  dulness,  and 
of  exaggeration  of  voice  at  any  part,  as  well  as  on  the  character  of  the  expectora- 
tion, which  is  less  adhesive  and  never  rusty.  Where  it  has  been  decided  that  the 
case  is  one  of  bronchitis  and  not  of  pneumonia,  we  have  still  to  account  for  the 
circumstance  of  one  lung  only  being  affected;  and  this  we  may  perhaps  learn 
from  the  history,  as  it  either  indicates  an  attack  of  inflammation  at  some  former 
period,  or  tells  of  gradual  emaciation,  haemoptysis  or  some  Other  symptom  of  com- 
tubercular  disease.  It  is  often  impossible  to  detect  the  signs  of  early 
phthisis  while  the  bronchitis  lasts ;  but  the  circumstance  of  the  morbid  sounds 
being  most  distinct,  and  lingering  longest  at  either  apex,  is  quite  enough  to  excite 
suspicion. 

Chronic  bronchitis,  when  it  occurs  for  the  first  time  in  any  given 
case,  is  probably  merely  an  unusual  prolongation  of  an  acute  attack 
which  has  been  neglected,  or  has  found  the  patient  in  a  condition 
of  general  debility;  the  history  is  merely  that  cough  has  continued 


BRONCHITIS.  249 

after  the  symptoms  of  febrile  disturbance,  pain,  &c,  have  subsided; 
the  expectoration  is  more  or  less  purulent;  the  auscultatory  signs 
give  no  evidences  of  consolidation ;  nothing  is  discovered  beyond 
the  persistence  of  moist  sounds.  In  such  cases,  however,  careful 
search  must  be  made  for  signs  of  early  phthisis. 

More  generally  there  is  a  history  of  previous  coughs  and  colds, 
and  the  present  attack  is  either  an  aggravation  of  a  constant  con- 
dition of  ill-health,  or  has  come  on  insidiously  without  acute  symp- 
toms :  there  seems  to  be  a  permanent  liability  to  chronic  inflamma- 
tion of  the  mucous  membrane,  and  this  is  sometimes  coupled  with 
a  condition  of  emphysema.  The  patient  is  not  feverish;  the  pulse 
is  sometimes  quick  and  weak,  and  the  tongue  may  be  accidentally 
foul;  but  it  is  not  dry,  and  there  is  no  heat  of  skin:  the  condition 
of  the  bowels  is  important,  because  occasional  diarrhoea  would  lead 
to  the  suspicion  of  phthisis.  If  emaciation  exist,  the  peculiar 
thinness  of  skin,  and  clubbed  nails  of  tubercle,  are  not  found  in 
simple  bronchitis;  the  face  is  often  discoloured,  dusky,  or  muddy, 
when  the  disease  is  severe,  becoming  remarkably  so  when  emphysema 
is  present,  and  having  a  more  distinctly  blue  or  purple  colour  when 
it  is  associated  with  disease  of  the  heart.  The  gait  is  stooping  in 
such  cases,  from  the  shoulders  being  elevated,  and  in  bed  the  patient 
cannot  lie  down;  orthopnoea  is  commonly  associated  either  with 
emphysema  or  disease  of  the  heart.  The  breathing  is  laboured, 
but  not  hurried :  the  cough  is  generally  frequent,  and  loose ;  the 
expectoration  usually  easy,  but  sometimes  only  possible  after  a  good 
deal  of  coughing:  it  is  muco-purulent,  or  almost  wholly  pus,  in 
simple  chronic  bronchitis;  it  is  watery,  frothy,  and  abundant  when 
the  bronchial  secretion  is  secondary  on  disease  of  the  heart  or  kidneys. 

Percussion  either  detects  no  difference  between  the  two  sides,  or 
excessive  resonance  is  especially  observed  on  one.  Sonorous  sounds 
seldom  exist  in  chronic  cases,  except  when  emphysema  is  present: 
moist  sounds  are  heard  loudest  at  the  back  of  the  chest,  and  in  the 
most  depending  positions,  where  they  are  louder  and  coarser  than 
elsewhere,  except  when  the  movement  of  the  air  in  the  small  tubes 
and  vesicles  is  impeded ;  and  then  scarcely  any  sound  is  heard,  or 
at  most  a  few  large  bubbles:  sometimes  local  absence  of  breathing, 
in  consequence  of  one  of  the  larger  tubes  being  temporarily  plugged 
up,  may  perplex  the  observer. 

In  chronic  bronchitis  it  is  to  be  remembered,  that  both  voice  and  breath  sounds 
may  be  locally  exaggerated  by  the  thickening,  dilatation,  and  rigidity  of  the  tubes, 
but  it  seldom  happens  that  such  changes  are  of  very  unequal  extent  on  the  oppo- 
site sides.  A  single  dilated  tube  at  one  apex  may  cause  some  difficulty  in  dia- 
gnosis; but  if  there  be  dulness  on  both  sides,  it  is  nearly  equal,  and  depends  only 
on  want  of  resiliency  of  the  ribs;  if  there  be  dulness  on  that  side  on  which  the 
large  tube  is  found,  its  real  interpretation  is,  that  there  is  excessive  resonance  on 
the  other,  where  want  of  breathing  indicates  emphysema;  if  resonance  be  more 
marked  over  the  dilated  tube,  it  has  none  of  the  hardness  and  hollowness,  or  local 
characters  of  a  cavity,  but  is  accompanied  by  elasticity  and  resilience.  This  is 
the  only  case  of  real  difficulty  in  chronic  bronchitis,  when  by  many  of  its  concur- 
rent symptoms  it  simulates  phthisis :  the  converse  case,  in  which  phthisis  simu- 


250  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

latea  chronic  bronchitis,  will  be  referred  to  in  \  9  of  this  chapter.     In  a  few  words 

we  may  say,  that  all  changes  of  percussion  resonance,  as  well  as  most  of  those 

connected  with  breath  and  voice-sounds,  indicate  something  besides  bronchitis; 

:■  tubercles,  or  emphysema,  or  pleuritic  effusion,  or  inflammatory  consolidation, 

ma:  and  the  correct  explanation  of  the  phenomena  depends  on  consi- 
derations belonging  to  each  of  those  states,  not  on  any  thing  specially  connected 
with  the  moist  sounds  themselves,  which  only  arise  from  the  coincident  bronchitis. 
Bronchorrhcea  is  probably  the  best  name  for  that  condition  of  the  Jungs  in  which 
the  secretion  from  the  mucous  membrane  is  due,  not  to  inflammation,  chronic  or 
acute,  but  to  secondary  congestion  induced  by  disease  of  the  heart,  or  more  pro- 
perly to  oedema  of  the  lung  associated  both  with  disease  of  the  heart  and  of  the 
kidneys.  Except  when  partial  dulness  is  produced  by  pleuritic  effusion,  there  is 
nothing  in  the  physical  signs  to  indicate  that  this  is  not  simple  bronchitis:  there  is 
usually  a  difference  in  the  expectoration,  when  there  is  no  inflammatory  condition 
of  the  membrane,  and  there  is  the  still  more  important  fact  of  disease  existing  in 
other  organs.  In  other  cases  bronchitis  is  engrafted  upon  persistent  disease  of 
the  heart  or  kidneys,  and  its  symptoms  are  greatly  aggravated  in  consequence. 
Complications  in  either  of  these  organs  are  the  most  common,  and  ought  espe- 
cially to  be  sought  for  in  chronic  cases;  after  all  that  has  been  said  it  is  scarcely 
necessary  to  repeat  that  the  existence  of  emphysema  and  tubercular  deposit  are 
each  to  be  inquired  into:  in  the  acute  form  we  find  bronchitis  complicating  pleu- 
risy and  pneumonia  or  even  pericarditis,  and  often  present  as  a  result  of  conges- 
tion in  cases  of  fever. 

§  7.  Emphysema  has  been  so  often  alluded  to  in 'the  preceding 
pages,  that  a  short  restwii  of  the  more  important  points  connected 
with  it  must  suffice.     Its  great  and  prominent  feature  is  dyspnoea 
— laborious,  in  contra-distinction  to  hurried  breathing;  the  respi- 
ration is  generally  slow,  and  yet  the  patient  is  conscious  of  dyspnoea, 
and  makes  complaint  of  it:  there  is  no  difficulty  of  articulation; 
but  yet  he  may  stop  in  the  narration  of  his  symptoms  to  take  breath. 
In  its  most  aggravated  form,  the  elevated  shoulders,  the  rounded 
back,  or  the  full,  highly-resonant  chest,  the  peculiar  weak,  power- 
less cough  and  voice,  and  the  dusky,  somewhat  earthy  or  muddy 
aspect,  are  all  so  striking  that  we  need  scarcely  institute  a  physical 
examination  to  satisfy  us  of  the  existence  of  emphysema.     Whether 
confined  to  one  lung,  or  extending  to  both,  the  phenomena  of  a 
well-marked  case  consist  of  slight  descent  of  the  upper  ribs  in 
expiration ;  their  heaving  movement,  with  but  little  expansion  of 
the  chest  in  inspiration,  while  the  lower  ribs  are.  drawn  inwards; 
excessive  resonance,  and  absence  of  breath-sound,  or  the  substitution 
of  prolonged  (\istant  expiration  for  vesicular  breathing.     It  is^  of 
most  importance  as  a  complication  of  chronic  bronchitis,  aggravating 
all   its   evils,  and  permitting  sometimes  such  an  accumulation   of 
secretion,  that  scarcely  a  bubble  reaches  the  ear,  although  the  tubes 
be  quite  full. 

In  its  minor  degrees  it  is  often  an  unexpected  cause  as  well  as 
complication  of  bronchitis:  the  obscurity  of  the  symptoms  some- 
times leads  to  its  being  mistaken  for  early  phthisis;  while  it  not 
unfrequently  affords  an  explanation  of  the  existence  of  asthma. 
When  the  upper  lobes  are  chiefly  implicated,  absence  of  voice-sound 
is  a  great  help  in  diagnosis;  but  this  is  far  from  being  constant: 
prolonged  sonorous  expiration  is  a  more  reliable  sign,  when  some 


ASTHMA.  251 

degree  of  bronchitis  is  present.  It  is  unnecessary  to  repeat  here 
the  circumstances  detailed  in  a  former  chapter  (Chap.  XVIII., 
Div.  I.,  §  3,)  by  which  we  decide  'whether  relative  dulness  on  per- 
cussion be  due  to  consolidation  of  a  portion  of  one  lung,  or  to 
dilatation  of  the  corresponding  part  of  the  other. 

Slight  general  emphysema,  in  the  absence  of  bronchitis,  gives 
rise  to  few  symptoms  by  which  it  may  be  detected.  The  patient 
perlpips  suffers  from  repeated  attacks  of  asthma,  or  any  little  cold 
is  attended  with  much  dyspnoea:  in  the  intervals  we  find  that  the 
inspiratory  sound  is  generally  weak  or  deficient,  or  a  rumbling 
noise  only  is  heard,  which  cannot  be  classed  as  inspiration  at  all ; 
but  on  deeper  breathing  some  little  sound  becomes  perceptible, 
which  is  followed  by  a  prolonged  distant  blowing  expiration.  These 
cases  are  difficult  to  discriminate  from  those  in  which  the  breath- 
sound  is  naturally  weak,  and  where  the  ear  may  be  applied  over  any 
part  of  the  chest  without  hearing  any  thing  in  ordinary  respiration. 

This  is  not  to  be  regarded  as  an  unnecessary  refinement ;  for  where  emphysema  is 
present,  there  is  to  a  certain  extent  less  chance  of  the  lungs  becoming  tubercu- 
lous than  when  the  breathing  is  naturally  weak.  Sometimes,  while  the  inspiration 
does  not  differ  from  that  generally  found  in  health,  the  expiration  is  universally 
prolonged.  Are  such  cases  at  all  emphysematous?  This  is  a  point  apparently 
somewhat  uncertain ;  but  I  conceive  that  one  of  the  elements  of  emphysema 
is  a  suppression  of  the  sound  of  inspiration,  and  that  its  distinctness  is  to  be 
regarded  as  exceptional  and  local,  and  that  it  only  occurs  in  consequence  of  dila- 
tation or  rigidity  of  some  tube  near  the  surface. 

As  the  emphysema  becomes  more  extensive,  so  do  the  attacks  of  breathlessness 
become  more  frequent  and  more  severe;  and  in  addition  to  the  ordinary  compli- 
cation of  bronchitis,  we  have  two  others  of  much  importance — hypertrophy  and 
dilatation  of  the  right  side  of  the  heart,  as  a  sequel  of  the  disease  of  the  lung,  and 
dyspeptic  symptoms,  which,  while  they  have  no  immediate  connexion  with  the 
condition  of  the  chest,  interfere  very  seriously  with  the  action  of  the  diaphragm. 
Both  tend  to  aggravate  the  dyspnoea:  the  one  by  sending  into  the  lungs  a  larger 
quantity  of  blood  than  they  can  supply  with  air,  the  other  by  preventing  the  al- 
ready distended  lungs  from  receiving  the  limited  supply,  which  each  inspiration 
might  otherwise  introduce:  the  former  is  permanent,  the  latter  only  temporary 
in  its  effects  upon  the  respiration. 

The  constancy  of  the  prolonged  sonorous  expiration  is  easily  explained  by  the 
loss  of  elasticity  of  the  air  vesicles,  which  deprives  the  lung  of  the  power  to  expel 
any  secretion  existing  in  the  tubes:  hence  it  is  that  sonorous  sounds  are  so  charac- 
teristic of  the  disease,  though  in  truth  they  depend  upon  bronchitis.  The  same 
circumstauce  explains  why,  with  a  larger  amount  of  secretion,  the  moist  sounds 
are  almost  suppressed;  because  the  air  is  stagnant  in  the  smaller  tubes,  and  the 
fluid  accumulates  till  but  a  few  bubbles  of  air  can  pass  through,  and  very  coarse 
sounds  only  are  heard  at  the  end  of  inspiration,  and  more  especially  at  the  be- 
ginning of  expiration. 

§  8.  Asthma. — In  speaking  of  the  descriptions  given  by  patients 
of  the  disease  under  which  they  are  labouring,  the  necessity  was 
shown  of  excluding  any  theory  which  the  name  given  to  the  com- 
plaint might  imply,  when  this  name  comprises  not  only  the  facts  of 
the  case,  but  the  notions  acquired  of  their  causation.  This  is 
especially  true  of  asthma;  and  when  a  patient  calls  himself  asth- 
matic, it  must  be  our  first  object  to  ascertain  whether  the  dyspnoea 


252  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

be  habitual,  and  of  long  continuance,  or  -whether  there  be  any 
paroxysmal  character  in  the  attack.  We  restrict  the  term  to  those 
s  in  which  the  difficulty  of  breathing  occurs  distinctly  in  pa- 
roxysms, of  longer  or  shorter  duration,  which  at  their  -worst  cannot 
exceed  a  couple  of  days,  and  more  generally  last  only  a  few  hours. 

In  such  instances  the  malady  comes  on  gradually.  At  first  it  is 
only  during  a  catarrh  that  any  shortness  of  breathing  is  experienced ; 
by  and  by  it  recurs  more  frequently,  and  with  greater  sev<#ity, 
cither  without  the  presence  of  catarrh  or  terminating  in  it;  and  de- 
pends on  such  a  variety  of  causes,  that  it  is  almost  impossible  to 
assign  the  true  one.  The  paroxysm  may  be  excited  by  local  or  at- 
mospheric causes,  or  by  derangement  of  stomach:  it  is  unattended 
with  fever,  the  skin  generally  being  cold,  and  often  covered  with 
moisture:  the  prominent  fact  is  inability  to  fill  the  chest  with  air, 
as  manifested  by  the  gasping  for  breath,  and  by  the  want  of  breath- 
sound  in  the  lungs,  while  there  is  no  permanent  cause  of  obstruction 
at  the  larynx  or  in  the  trachea,  the  patient  having  been  quite  free 
from  dyspnoea  before  the  paroxysm  began,  and  knowing  full  well 
that  he  will  be  free  from  it  as  soon  as  it  is  over. 

In  a  very  large  number  of  these  cases  there  is  some  degree  of 
emphysema;  and  the  more  the  lungs  are  thus  altered  the  more  easily 
is  the  asthma  excited,  the  more  severe  is  it  while  it  lasts,  and  the 
longer  its  continuance.  But  there  are  cases  in  which  we  can  trace 
no  emphysema,  and  we  are  cognizant  of  nothing  but  the  spasm  by 
which  the  air  is  prevented  from  entering  the  lungs  with  its  ordinary 
freedom.  The  paroxysms  are  most  apt  to  occur  at  night;  and,  be- 
sides the  immediate  object  of  shortening  their  duration,  we  have  to 
consider  their  relation  to  local  causes,  or  disordered  stomach,  with 
a  view  to  their  prevention. 

Hay-asthma  is  really  a  catarrh,  and  has  nothing  of  the  parox- 
ysmal character.  It  cannot  be  distinguished.from  ordinary  catarrh, 
except  by  its  recurring  at  the  same  season  of  the  year,  by  its  being 
excited  in  the  immediate  proximity  of  its  known  cause,  or  by  its 
surprising  and  almost  immediate  cessation  on  removal  from  such 
proximity:  these  discoveries  are  more  frequently  due  to  accident 
than  to  skilful  diagnosis. 

All  other  so-called  asthmatic  cases  maybe  resolved  into  changes 
in  the  permanent  condition  of  the  lungs,  or  diseases  of  the  heart  and 
blood-vessels. 

§  9.  Phthisis  Pulmonalis. — The  existence  of  tubercles  in  the 
lungs  is  only  the  local  expression  of  a  general  disease  called  by 
some  a  blood-crasis,  by  others  a  diathesis.  Allied  to  scrofula,  it  is 
placed  in  the  table  of  diseases  among  the  chronic  blood  ailments, 
but  its  most  constant  manifestation  is  in  disease  of  the  lungs ;  and 
it  was  therefore  thought  better  to  defer  its  consideration  until  we 
had  reviewed  the  other  diseases  of  these  organs. 

In  its  characteristic  form  and  advanced  stage,  both  general  symp- 


PHTIIISIS   PULMONALIS.  253 

toms  and  local  phenomena  are  so  distinct  that  no  disease  is  more 
readily  or  more  surely  recognised:  in  exceptional  cases  it  is  not  un- 
frequently  mistaken  for  other  diseases,  while  they  in  their  turn  are 
liable  to  simulate  phthisis:  in  its  early  manifestation  it  is, very  im- 
portant to  be  able  to  recognise  it  while  yet  latent,  and  before  its 
symptoms  are  fully  developed.  Its  sadly  fatal  course  makes  the 
conscientious  practitioner  view  these  early  phenomena  with  great 
anxiety,  and  study  their  relations  with  the  greatest  care;  as  the 
dread  in  which  it  is  universally  held  serves  as  a  never-failing  resource 
for  the  fraudulent  and  the  avaricious,  who  pretend  to  detect  phthisis 
when  it  does  not  exist,  and  promise  a  cure  alike  to  those  whom  they 
thus  deceive  as  to  the  true  nature  of  their  malady,  and  to  those 
whom  they  delude  with  false  hopes  as  to  the  powers  of  art  when 
their  case  is  already  past  recovery. 

The  history  comprises  several  points  of  considerable  value  in  dia- 
gnosis: loss  of  relatives  from  diseases  of  the  chest  under  whatever 
name,  especially  those  occurring  at  the  period  of  adolescence ;  ac- 
counts of  previous  illnesses  and  ailments  of  the  patient  himself;  and 
the  mode  in  which  his  present  attack  has  commenced.  It  must  be 
regarded  as  unfavourable  when  cough  has  begun  without  preceding 
catarrh  or  coryza,  but  has  been  from  the  first  dry  and  hacking;  when 
during  its  continuance,  or  at  its  beginning  there  has  been  haemopty- 
sis of  the  amount  of  a  teaspoonful  or  more;  and  when  in  the  pro- 
gress of  the  case  the  dry  cough  has  been  changed  for  one  accompa- 
nied by  thin  mucilaginous  rice-water  sputa,  and  that  form  of  expec- 
toration has  been  followed  by  thick  yellow  phlegm. 

The  general  symptoms  very  often  indicate  the  presence  of  hectic ; 
the  skin,  especially  that  on  the  palms  of  the  hands,  being  at  times 
dry  and  hot,  while  at  others  it  is  bedewed  with  excess  of  moisture ; 
there  are  also  night-sweats,  the  pulse  is  quick  and  weak,  the  tongue 
frequently  patchy,  and  sometimes  preternaturally  red,  shining,  or 
smooth.  Along  with  this  we  have  the  particular  indications  of  re- 
markable thinness  of  the  skin,  which  can  be  pinched  up,  as  if  it 
were  detached  from  the  subcutaneous  structure,  and  clubbing  of 
the  nails,  with  the  occasional  presence  of  diarrhoea:  any  signs  of 
emaciation  are  of  value  when  not  traceable  distinctly  to  disease  of 
the  chylopoietic  viscera.  The  patient's  appearance  sometimes  be- 
trays weakness  with  a  mixture  of  languor  and  excitability;  the  eye 
brilliant,  the  cheek  pale,  with  a  hectic  flush,  and  the  whole  aspect 
delicate.  The  respiration  is  observed  to  be  quick,  while  the  patient 
has  no  feeling  of  dyspnoea,  and  does  not  seek  by  posture  to  relieve 
his  breathing.  No  complaint  of  cough,  perhaps,  is  made  till  it  be 
inquired  after ;  there  may  be  mention  of  wandering  pains  in  the 
chest,  of  a  feeling  of  tightness,  or  perhaps  of  local  pain  from  inter- 
current pleurisy.  The  voice  is  very  often  characterized  by  a  slight 
degree  of  hoarseness,  which,  as  the  disease  proceeds,  may  ultimately 
terminate  in  complete  aphonia. 

None  of  these   symptoms   are   always   present,  and  some   are 


254  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

very  liable  to  be  found  in  other  diseases,  but  one  or  two  have  more 
value  than  the  rest.  Among  these  we  reckon  family  history;  hae- 
moptysis, when  there  is  no  disease  of  the  heart,  no  r|Jaxed  throat 
or  spongy  gums;  quick  pulse  and  night-sweats,  thin  skin,  clubbed 
nails  and  emaciation:  especially  when  these  are  found  about  the  pe- 
riod of  puberty,  and  from  that  onward  to  the  age  of  thirty.  He- 
moptysis is  studiously  concealed  by  some  patients,  in  whom  it  has 
really  existed,  is  much  talked  of  by  others  in  whom  it  has  been  only 
simulated,  especially  the  hysterical  and  hypochondriac.  The  quick- 
ness of  the  pulse  is  generally  an  index  of  the  severity  of  the  dis- 
ease ;  and  a  natural  pulse,  when  the  evidence  of  phthisis  is  distinct, 
is  always  a  favourable  indication  as  to  the  progress  of  the  case. 
Clubbed  nails  seem  to  have  some  direct  relation  to  the  condition  of 
the  lungs  and  heart,  and  though  most  commonly  seen  in  phthisis,  yet 
attain  even  higher  degrees  of  development  in  rare  cases  of  disease 
of  the  chest,  when  not  a  tubercle  exists. 

The  auscultatory  phenomena  vary  according  to  the  site  of  the 
deposit  and  the  progress  it  has  already  made.  An  important  fact 
in  their  elucidation  is,  that  tubercle  has  a  remarkable  tendency  to 
be  located  in  the  apex  of  the  lung;  and  that  however  disseminated 
through  other  parts  of  the  organ,  it  is  very  generally  found  there 
too ;  this  law  is  all  but  universal :  the  converse  is  also  true  to  a 
less  extent;  that  in  other  diseases  of  the  lungs  the  signs  are  more 
fully  developed  in  other  parts:  we  shall  therefore  consider  the  symp- 
toms of  tubercles  at  the  apex  first.  The  facts  of  which  auscultation 
and  percussion  in  this  region  give  evidence  are  the  original  deposit 
of  tubercle  in  solitary  small  masses,  their  gradual  increase  in  size, 
the  excavation  of  the  lung  which  follows  on  their  softening  and  ex- 
pulsion ;  and  incidentally  inflammation  and  irritation  of  the  bronchial 
tubes,  of  the  pleura,  or  even  of  the  parenchyma  of  the  lung,  which 
may  be  excited  by  their  presence. 

If  the  previous  chapters  have  been  carefully  studied,  the  pheno- 
mena necessarily  resulting  from  such  causes  will  be  known  a  priori. 
A  very  small  amount  of  deposit  can  only  affect  the  breathing  in  the 
way  of  making  the  expiration  a  little  longer,  and  the  inspiration 
a  little  shorter,  and  harsher  or  louder,  or  perhaps  weaker,  than 
on  the  opposite  side,  or  by  giving  it  a  wavy  or  jerking  character: 
the  voice-sound  will  be  a  little  louder :  the  percussion-sound  can 
only  be  very  slightly  if  at  all  altered;  but  it  must  not  be  forgotten 
that  both  voice  and  breath-sounds  have  a  tendency  to  be  louder  on 
the  right  than  on  the  left  side  in  health.  Sometimes  a  confirmation 
of  the  existence  of  tubercle  in  this  early  stage  may  be  _  obtained 
from  the  heart's  sounds  being  heard  more  loudly  at  the  fight  apex 
than  the  left,  which  is  impossible  in  health ;  a  bruit  in  the  subclavian 
artery,  when  it  cannot  be  heard  in  the  carotid  or  at  the  heart,  is 
also  of  value,  although  the  rationale  of  its  development  is  not  under- 
stood. These  are,  after  all,  very  uncertain  grounds  on  which  to 
determine  that  so  serious  a  disease  as  phthisis  has  begun,  and  yet 


PHTHISIS    PULtaONALIS.  255 

they  are  sometimes  all  that  auscultation  and  percussion  afford.  An 
opinion  ought  not  to  be  pronounced  on  such  insufficient  data,  if 
standing  alone ;  but  we  may  feel  very  safe  in  the  deduction,  if  the 
history  and  general  symptoms  point  to  the  probability  of  phthisis, 
and  if  the  physical  signs  be  only  taken  in  conjunction  with  the 
whole  evidence  which  the  case  supplies.  Above  all,  let  me  warn, 
the  student  against  supposing  that  he  is  reasoning  accurately  in 
taking  them  in  conjunction  with  only  one  of  the  more  general 
symptoms;  such,  for  example,  as  a  weak  and  quick  pulse,  or 
lueuioptysis :  this  is  the  most  common  cause  of  error. 

As  the  disease  proceeds,  the  evidence  of  consolidation  becomes 
more  distinct,  and  along  with  it  we  have  signs  of  irritation  of  the 
bronchial  tubes  (sonorous  and  moist  sounds,)  of  inflammation  of  the 
pleura  (friction  and  creaking  sounds,)  sometimes  of  inflammation  of 
the  parenchyma  (true  crepitation,)  or  of  the  progress  of  the  tuber- 
cular disease  itself  (clicking  or  crumpling  sounds;)  and  we  admit 
the  great  probability  that  these  signs  are  caused  by  the  presence  of 
tubercle:  yet  we  cannot  dispense  with  the  evidence  derived  from 
the  history  of  the  case,  because  they  only  prove  local  consolidation, 
and  no  more,  and  this  may  be  inflammatory. 

Still  further  in  the  progress  of  the  case,  the  evidence  of  local 
consolidation  is  accompanied  by  louder  blowing  breath-sound  from 
commencing  excavation  when  the  cavities  are  empty;  and  at  a 
more  advanced  stage,  the  dull  percussion  stroke  may  be  converted 
into  something  approaching  to  tympanitic  hollowness ;  the  breath- 
sound  is  still  more  blowing,  and  the  voice-sound  is  sometimes  pain- 
fully loud,  as  if  some  one  were  speaking  into  the  other  end  of  the 
stethoscope ;  this  cavernous  sound,  as  it  is  called,  is  Tsven  more 
clearly  brought  out  occasionally  when  the  patient  whispers.  The 
necessary  result  of  air  entering  these  cavities  when  fluid  is  present 
is,  that  the  superadded  sounds  become  bubbling,  gurgling,  or  even 
metallic.  An  important  fact  in  relation  to  this  stage  of  the  disease 
especially,  is  flattening  or  sinking  of  the  ribs,  and  deficient  move- 
ment in  inspiration ;  without  this  our  signs  of  excavation  are  pro- 
bably altogether  wrong,  and  we  must  look  for  some  other  explana- 
tion. The  general  symptoms,  too,  are  necessarily  more  pronounced, 
and  the  history  of  the  disease  extends  over  a  longer  period. 

The  principal  fallacy  in  the  first  stage  is  when  the  healthy  lung  is 
supposed  to  be  tubercular  because  the  opposite  one  is  emphysema- 
tous: in  the  second,  when  pneumonia  of  the  upper  lobe  is  mistaken 
for  tubercular  consolidation:  in  the  third,  when  a  large  tube  is  mis- 
taken for  a  cavity,  or  a  large  cavity  is  mistaken  for  pneumo-thorax. 
In  chronic  pleurisy  with  empyema,  attended  by  symptoms  of  hectic, 
sounds  exactly  resembling  those  produced  by  tubercular  deposit 
may  be  heard  under  the  clavicle:  the  practitioner  must  be  thrown 
much  off  his  guard  by  some  unusual  circumstance,  who  confounds 
these  two  conditions ;  but  what  has  happened  more  than  once  within 
my  own  personal  knowledge,  may  happen  again. 


256  DISEASES    OF   TOE  ©ESPIRATOKY    OBGANS. 

p 

For  the  sake  of  the  student  we  tnaj  point  OUl  more  in  detail  the  relations  which 
superadded  sounds  present  to  the  different  modifications  of  breath  and  voice-sound 
xved  in  the  progress  of  the  disease. 

The  voice-smiml  steadily  increases  in  intensity  from  the  beginning  of  consolida- 
tion to  its  ultimate  termination  in  the  largest  possible  cavity.  Not  so  the  breath- 
sound:  this  is  first  commonly  harsh  and  i  rated,  or  wavy  and  jerking:  then 
the  inspiration  becomes  diminished  in  intensity  while  the  expiration  is  prolonged; 
anl  subsequently,  when  cavities  begin  to  form,  each  increases  in  loudness,  but 

expiration  more  especially  becomes  remarkably  blowing.  With  the  first  i 
dition  BQperadded  sound  is  usually  absent;  sometimes  a  crumpling  sound  may  be 
heard  on  deep  inspiration,  but  if  the  presence  of  tubercular  matter  give  rise  to 
any  inflammation,  fine  and  coarse  crepitation  or  moist  and  sonorous  sounds  are 
developed;  the  variations  probably  depending  upon  whether  the  vesicular  structure 
or  the  tabes  be  more  particularly  the  seat  of  the  inflammatory  action.  Proceeding 
a  little  further,  the  sonorous  sound  is  entirely  replaced  by  moist  sound,  when  the 
secretion  from  the  tubes  becomes  more  abundant;  but  in  the  same  proportion 
does  tin-  air  find  difficulty  in  entrance,  and  the  breath-sound  becomes  partially 
suppressed:  this  condition  is  not  necessarily  permanent,  and  the  lung  may  return 
to  one  in  which  the  breathing  is  simply  harsh  and  exaggerated.  At  this  stage 
tin'  presence  of  crumpling  or  of  friction-sound  or  of  one  or  two  clicks  is  often  of 
gre;r  •  in  giving  certainty  to  the  diagnosis,  when  bronchial  irritation  has 

passed  away. 

In  the  second  period  the  difference  in  resonance  becomes  quite  distinct:  but 
the  student  may  feel  uncertain  which  of  the  two  is  the  diseased  lung,  unless  he 
compare  the  sound  of  the  percussion  stroke  above  and  below  on  each  side  of  the 
chest.  The  moist  clicks  now  become  more  frequent,  and  are  often  mixed  up  with 
squeaking  sounds;  coarse  crepitation  and  sonorous  sounds  are  more  rare,  or  are 
heard  only  in  the  vicinity  of  where  the  softening  has  begun;  moist  sounds  are 
common.  There  are  two  circumstances  which  tend  to  produce  these  effects,  the 
partial  softening  of  small  tuberculous  masses,  and  the  presence  of  local  bronchitis; 
and  though  clicks  and  squeaking  sounds  be  more  distinctive  of  the  former,  and 
moist  sounds  of  the  latter,  yet  they  are  by  no  means  to  be  taken  as  their  di- 
rect exponents,  because  each  may  be  found  in  either  circumstance.  Another 
cause  of  the  presence  of  moist  sounds  with  deficient  breathing  is  the  recent  oc- 
currence of  hemoptysis :  dulness  is  commonly  present,  but  it  is  slightly  marked: 
the  circumstance  of  hemorrhage  having  existed  sufficiently  explains  the  pheno- 
menon, and,  when  heard  only  at  the  apex,  moist  sounds  are  pretty  conclusive 
evidence  that  its  cause  is  the  previous  deposition  of  tubercular  matter,  because 
we  know  of  none  other  which  can  give  rise  to  hemorrhage  at  the  upper  part  of  the 
lung  only.  As  a  necessary  consequence  of  the  presence  of  the  fluid,  whatever  it 
may  be,  that  produces  these  sounds,  the  entrance  of  air  is  impeded  and  the 
breathing  is  deficient. 

Advancing  still  further,  the  dulness  becomes  unmistakable:  indeed,  the  wooden 
or  tympanitic  sound  over  a  cavity  would  always  be  called  dull  by  any  but  an  expert 
auscultator.  The  moist  sounds  become  coarse,  abundant,  and  mixed  with  larger 
bubbling,  until  a  cavity  of  some  size  has  formed,  and  then  nothing  but  gurgling 
sounds  are  heard,  when  the  stethoscope  is  applied  over  it:  in  its  immediate  neigh- 
bourhood the  signs  are  those  of  less  advanced  disease.  "When  numerous  smaller 
cavities  exist,  the  condition  is  one  of  more  general  coarse  or  bubbling  moist 
sounds.  But  besides  the  size  of  the  cavity,  the  proportion  of  air  and  fluid  which 
it  contains  greatly  modifies  the  sounds  it  gives  out,  and  we  may  have  no  super- 
d  sound  at  all  from  the  absence  of  either  one  or  other.  An  empty  cavity 
produces  a  loud  blowing  sound  in  breathing,  but  no  gurgling;  a  full  cavity  gives 
neither  one  nor  other,  but  only  dulness  on  percussion;  a  cavity  communicating 
freely  with  the  bronchial  tubes  by  an  opening  situated  below  the  level  of  the  fluid 
produces  loud  gurgling;  one  in  which  a  small  opening  is  similarly  situated  may 
give  rise  to  only  one  or  two  resonant  explosions:  when  the  cavity  is  large  and 
nearly  empty,  every  sound  produced  within  it  has  a  metallic  resonance;  in  a  small 
cavity  or  one  nearly  full  no  such  effect  occurs. 

There  need  be  no  practical  difficulty  in  distinguishing  this  metallic  clang  from 


PHTHISIS   PULMONALIS.  257 

that  produced  by  a  similar  cause  on  a  much  larger  scale,  viz.,  the  presence  of  air 
and  fluid  together  in  the  pleura:  the  great  and  constant  distinction  is  simply  that 
in  the  one  case,  if  we  turn  to  the  back  of  the  chest,  we  find  the  indications  of  lung 
tissue,  however  diseased,  occupying  its  natural  position;  in  the  other  we  have  the 
tympanitic  resonance  produced  by  its  absence;  and  if  any  breathing  be  heard,  it 
is  only  a  loud  blowing  sound  resounding  through  the  empty  cavity,  while  at  the 
base  there  is  complete  dulness,  from  the  presence  of  fluid,  and  no  breathing  at  all. 
In  additiou  to  this  there  are  two  minor  sources  of  information:  the  metallic  sound 
is  seldom  produced  by  dropping  when  heard  in  a  cavity,  but  is  more  commonly 
the  result  of  solitary  bubbles  of  air  passing  through  the  fluid ;  it  therefore  keeps 
time  with  the  breathing — dropping  does  not :  the  voice  is  less  like  that  produced 
by  speaking  into  an  empty  jar,  and  seems  rather  to  be  spoken  into  the  stethoscope. 
The  student  must  be  reminded,  too,  of  the  possibility  of  a  portion  of  air  spon- 
taneously developed,  £>r  admitted  by  paracentesis,  rising  to  the  apex  when  the 
lung  is  not  shrunken  as  it  is  in  true  pneumo-thorax,  and  when  there  is  no  commu- 
nication between  the  bronchi  and  the  pleura.  He  has  only  to  think  of  the  fact  that, 
if  there  be  at  the.  apex  a  cavity  capable  of  causing  tympanitic  resonance,  there 
must  be  blowing  breath-sound  and  loud  voice;  when  there  is  air  in  the  pleura  just 
the  opposite  effect  is  produced,  and  both  sounds  are  less  loud  than  on  the  oppo- 
site side. 

Another  general  pathological  fact  may  be  turned  to  account  in 
diagnosis — viz.,  that  if  tubercles  be  at  all  advanced  in  one  lung, 
they  are  almost  certain  to  exist  in  minor  degree  in  the  other;  and 
when  their  presence  is  equally  distinct  in  both  lungs,  they  are  still 
seldom  found  in  exactly  the  same  stage,  or  giving  rise  to  the  same 
modifications  of  sound.  This  is  especially  to  be  borne  in  mind  when 
any  one  auscultatory  phenomenon  stands  alone  at  either  apex  in  a 
very  marked  degree,  which  would  indicate  an  advanced  stage  of  the 
disease,  if  it  were  found  in  conjunction  with  other  corresponding 
signs  and  symptoms ;  alone,  we  must  be  content  to  regard  it  as  an 
anomaly  to  be  hereafter  cleared  up  as  the  disease  proceeds ;  but  Ave 
may  consider  the  possibility  of  morbid  growth, — such,  for  instance, 
as  encephaloid  disease  disseminated  at  the  apex.     (See  §  10.) 

Tubercular  disease  is  sometimes  found  solely  or  chiefly  at  the  base  of  the  lung: 
such  cases  are  very  apt  to  be  misunderstood  simply  from  the  fact  that  they  are  so 
rare.  When  dulness  on  percussion  is  perceptible,  and  the  morbid  sounds  are  li- 
mited to  one  side  of  the  chest,  the  phenomena  may  be  caused  either  by  chronic 
pneumonia,  or  by  old  thickening  of  the  pleura  with  bronchitis  confined  to  that 
lung.  Gurgling  or  clicking  sounds,  showing  that  softening  was  going  on  and  ca- 
vities were  forming,  would  negative  both  of  these  hypotheses,  because  abscess 
without  tubercle  is  attended  with  fetor:  more  reliance,  however,  is  to  be  placed  on 
the  history  of  the  case;  long  duration,  gradual  progress,  and  the  absence  of  any 
distinct  acute  attack,  all  point  more  directly  to  tubercle,  and  when  found  in  con- 
junction with  general  symptoms  of  phthisis,  must  be  held,  if  not  as  conclusive, 
yet  as  affording  grounds  for  very  grave  suspicion.  Still  more  decidedly  would  this 
view  ot  the  case  be  the  correct  one  if  with  the  dulness  the  morbid  sounds  were  to 
be  heard  on  both  sides  of  the  chest,  but  more  loudly  on  the  duller  side.  In  other 
instances  phthisis  of  this  particular  form  closely  simulates  bronchitis;  and  this  is 
the  more  common  case,  because  the  difference  on  percussion,  when  both  lungs  are 
more  or  less  affected,  is  not  readily  made  out,  and  there  is,  in  truth,  some  amount 
of  coincident  bronchitis  caused  by  the  tubercular  deposit.  This  subject  has  been 
already  fully  considered,  and  it  is  one  which  requires  very  nice  discrimination. 
(See  Chap.  XIX.,  Div.  II.,  §  4  d.)  The  existence  of  haemoptysis,  beyond  what 
mere  straining  might  cause,  of  emaciation,  quick  pulse,  thin  skin,  clubbed  nails, 
or  any  of  the  more  important  symptoms  of  phthisis,  ought  to  put  us  on  our  guard 
against  pronouncing  too  favourable  a  diagnosis  iu  such  cases. 

17 


Dl         OF  THE  RESPIRATORY  ORGANS. 

[|      a  1       rare  occurrence  to  meet  with  tubercles  equally  disseminated  through 

the  lung:  Buch  cases  arc  almost  always  recent,  and  this  fact  alone  tends  greatly  to 

ie  diagnosis.    Still  the  history  wants  something  of  the  severity  of  an 

lack;  it  is  insidious;  there  is  not  immediate  prostration,  but  gradual  de- 
cline; there  is  often  hasr  j  the  B  hrile  symptoms  are  commonly  of  mild  cha- 
racter, but  the  pulse  is  quicker  than  the  other  symptoms  would  lead  us  to  ex] 
emaciation  cannot  have  proceeded  far,  nor  can  there  he  hectic  fever  till  softening 
have  commenced;  commonly  there  is  a  general  blue  discoloration  of  the  t 
which  most  nearly  resembles  th:  in  severe  bronchitis;  it  differs  from  the 

ash  of  pneumonia,  as  well  as  from  the  bloeness  of  diseased  heart,  and  the 
dirty  hue  of  emphysema;  it  is  rather  a  flush  or  suffusion  of  face  which,  if  the  1:, 
were  healthy,  would  be  florid,  and  is  dark-coloured  only  because  the  vesicles 
obstructed.  The  physical  signs  at  first  resemble  pneumonia,  but  of  such  an  ex- 
t"iisive  character  that  they  cannot  possibly  be  caused  by  acute  inflammation  where 
the  general  symptoms  are  so  moderate:  indeed,  the  sounds,  when  more  carefully 
studi  not  exactly  those  of  pneumonia;  the  crepitation  is  coarser  and  more 

■  ■initiated,  the  breathing  and  vocal  resonance  are  both  free  from  any  brassy 
t  ;ie,  till  the  phenomena  are  more  distinct  at  the  upper  part,  and,  unlike  pneumo- 
nia, they  are  not  strictly  confined  to  one  lobe,  but  gradually  decrease  towards  the 

■  of  the  lung:  the  expiration  is  simply  harsh  and  prolonged,  and  the  voice  ex- 
rated.     At  a  later  stage  the  signs  resemble  those  of  bronchitis,  but  the  moist 

Bounds  are  fewer  and  more  squeaking,  with  prolonged  expiration,  especially  at  the 

apex,  which  is  not  the  case  in  bronchitis.  Some  difference  on  percussion  between 
;wo  sides  of  the  chest  is  generally  distinct,  but  the  same  characters  in  slighter 
ree  are  found  on  the  opposite  side.     If  one  lung  present  such  signs  of  disease, 

while  in  the  other  consolidation  is  commencing  at  the  apex,  most  unquestionably 

the  whole  is  due  to  tubercular  deposit. 

In  early  phthisis,  when  the  signs  are  still  obscure,  considerable 
difficulty  in  making  a  correct  diagnosis  may  arise  from  the  coexist- 
ence of  bronchitis:  on  the  one  hand,  we  may  recognise  the  bron- 
chitis, and  reason  correctly  regarding  that,  and  yet  be  quite  wrong 
in  prognosis,  because  of  overlooking  the  presence  of  tubercles ;  on 
the  other,  we  may  recognise  the  phthisis,  and  come  to  very  false 
conclusions  regarding  its  progress,  because  of  attributing  to  it  signs 
which  are  in  reality  due  to  bronchitis.  When  along  with  an  attack 
of  bronchitis  we  observe  general  symptoms  leading  to  a  suspicion  of 
phthisis,  it  is  wise  to  wait  before  giving  an  opinion  as  to  the  tuber- 
cular or  non-tubercular  character  of  the  disease  until  the  former 
have  disappeared;  it  is  a  very  suspicious  circumstance  when  the 
morbid  sounds  linger  at  the  apices  after  they  have  ceased  in  other 
parts  of  the  chest:  and  this  is  still  more  true  of  bronchitis  limited 
to  one  lung;  the  very  fact  of  the  limitation  offers  a  presumption 
that  there  is  something  abnormal  in  the  lung  so  affected. 

Another  common  complication  of  phthisis  is  partial  pleurisy  near 
the  apex  of  the  lung:  but  the  attack  is  not  always  so  limited,  and 
sometimes  general  pleurisy  occurs  when  the  lungs  are  already  tu- 
bercular. It  has  been  already  mentioned  that  the  sounds  heard  in 
the  clavicular  region,  when  the  lung  is  condensed  by  pleuritic  effu- 
sion, are  exactly  those  of  consolidation  with  a  cavity  subjacent: 
the  percussion  sound,  while  dull,  has  often  a  sort  of  tympanitic  re- 
sonance; the  breath-sound  is  remarkably  blowing,  with  prolonged 
expiration;  the  voice  loud  and  ringing;  and  if  bronchitis  be  pre- 
sent, moist  sounds  are  also  heard;  but  with  moderate  care  such  a 


TUMOURS.  259 

condition  ought  not  to  be  mistaken  for  phthisis.  During  the  exist- 
ence of  pleurisy  it  is  very  unwise  to  give  an  opinion  regarding  the 
presence  of  tubercle.  It  is  alleged  by  authors  that  double  pleurisy 
is  a  suspicious  circumstance ;  probably  indicating  a  complication  of 
phthisis,  and  the  hint  should  not  be  lost  sight  of;  but  it  amounts  to 
no  more  than  a  mere  suggestion.  Chronic  pneumonia,  if  the  term 
be  used  at  all,  may  be  applied  to  the  condition  of  the  lungs  met 
with  at  one  stage  of  tubercular  deposit,  particularly  when  the  dis- 
ease is  widely  disseminated:  a  more  active  form  may  be  excited  by 
its  rapid  development  in  the  upper  lobe,  which  during  its  existence 
obscures  any  evidence  of  phthisis;  but  in  a  decided  attack  of 
sthenic  pneumonia,  we  may  feel  great  confidence  that  there  is  no . 
tubercle:  such  at  least  has  been  the  rule  in  cases  coming  under  my 
own  observation,  and  the  nature  of  the  two  diseases  is  so  distinct, 
that  it  is  exactly  what  a  priori  we  have  reason  to  expect. 

Severe  and  commonly  fatal  meningitis,  in  the  form  of  acute  hy- 
drocephalus, is  frequently  found  in  the  tubercular  diathesis;  and 
when  inflammation  of  tbe  brain  occurs  about  the  period  of  adoles- 
cence, it  will  often  be  possible  to  determine  its  nature  by  an  exami- 
nation of  the  lungs.  Chronic  peritonitis  at  the  same  age  is  another 
disease  which  very  commonly  has  a  tubercular  origin,  and  calls  for  a 
similar  examination.  Diarrhoea  may  be  rather  regarded  as  a  direct 
symptom  than  as  a  complication  of  phthisis. 

§  10.  Tumours. — These  have  been  referred  to  in  speaking  of  the 
causes  of  dulness  on  percussion ;  and  while  certain  phenomena 
have  been  pointed  out  as  possibly  explicable  on  the  hypothesis  of 
their  existence,  no  signs  have  been  mentioned  as  direct  proofs  of  it: 
more  true  wisdom  is  often  shown  in  a  confession  of  ignorance  than 
in  an  assumption  of  knowledge ;  and  though  a  man  of  large  expe- 
rience and  pathological  knowledge  may  sometimes  give  a  shrewd 
guess  at  the  true  solution  of  the  difficulty,  there  are  points  which 
render  it  almost  impossible  to  reason  correctly,  because  the  facts 
are  not  only  wanting,  but  to  a  certain  extent  unattainable.  In  such 
circumstances  we  must  be  content  with  the  sort  of  empirical  know- 
ledge which  amounts  to  no  more  than  this — "  I  have  seen  such 
and  such  a  case,  and  it  turned  out  so  and  so,  and  I  think  it  highly 
probable  that  this  case  will  have  a  similar  termination."  Such 
knowledge  is  the  reward  of  careful  observation,  and  is  one  of  the 
most  valuable  acquisitions  of  the  accomplished  physician. 

Tumours  in  the  chest  are  either  aneurism  or  morbid  growth.  The 
latter  is  found  sometimes  disseminated  through  the  lung,  sometimes 
developed  from  the  glandular  structure  at  its  root,  or  attached  to 
the  parietes ;  and  the  indications  will  necessarily  vary  according  to 
its  site:  the  former,  from  the  situation  of  the  great  vessels,  presents 
symptoms  somewhat  analogous  to  that  of  growths  from  the  root  of 
the  lung. 

The  history  of  these  cases  is  so  far  alike,  that  there  is  never 


260  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

aiiv  thing  to  fix  a  correct  date  for  their  commencement,  because  in 
instances  the  patient  has  only  become  conscious  of  inconve- 
nience when  some  other  disease  has  supervened.  Neither  do  parti- 
cular classes  or  forms  of  growth  produce  any  constant  series  of 
effects,  the  phenomena  being  commonly  casual  or  accidental,  and 
not  essential.  The  patient  generally  complains  of  cough  anj  dys- 
pnoea, and  sometimes  of  pain:  difficulty  of  breathing  is  most  per- 
ceptible when  the  tumour  presses  on  some  of  the  large  tubes. 

The  discovery  of  cancer  or  of  aneurism  elsewhere,  in  situations 
where  their  nature  is  more  easily  recognised,  or  signs  of  disease  of 
the  heart,  would  give  significance  to  symptoms  otherwise  anomalous: 
no  reliance  can  be  placed  on  the  absence  of  what  is  called  the 
"malignant  aspect,"  because  the  colour  of  the  face  is  so  liable  to 
be  altered  by  the  condition  of  the  lungs;  interference  with  the  pro- 
per aeration  of  the  blood  necessarily  produces  a  dusky  hue. 

Nodules  of  encephaloid  disease  may  cause  modifications  in  per- 
cussion resonance,  and  in  the  character  of  the  breath-sound,  or 
they  may  give  rise  to  bronchial  secretion  and  moist-sound;  and 
most  frequently  the  latter  is  the  only  evidence  of  disease.  "We  can 
do  no  more  than  satisfy  ourselves  that  the  balance  of  evidence  is 
against  the  existence  of  phthisis  as  its  cause.  Scirrhus  perhaps 
gives  rise  to  more  important  changes  in  the  breathing  and  vocal 
resonance,  and  the  physical  signs  are  very  like  those  caused  by  a 
vomica,  while  the  condition  of  the  opposite  lung  is  unlike  that  which 
is  produced  by  tubercular  deposit,  and  the  general  symptoms  do  not 
point  to  such  an  advanced  condition  of  phthisis  as  implies  the 
formation  of  a  cavity.  Sometimes  the  appearance  of  peculiar 
expectoration,  which  has  been  compared  to  thin  currant-jelly,  gives 
an  assurance  of  the  true  character  of  the  disease;  but  it  must  be 
confessed  that  very  little  can  be  done  in  making  out  the  diagnosis 
of  such  cases. 

Tumours  at  the  root  of  the  lungs  are  more  easily  recognised 
when  the  disease  has  made  some  progress ;  in  their  early  stage  there 
is  nothing  to  point  out  their  existence.  As  soon  as  they  are  of 
sufficient  size  to  produce  pressure  on  the  bronchi,  there  will  be  irri- 
tation, probably  secretion,  and  fits  of  dyspnoea,  closely  resembling 
asthma:  of  still  larger  size,  they  are  apt  to  cause  dysphagia,  or  to 
interrupt  the  current  of  the  circulation;  and  now  the  patient  begins 
to  find  out  that  in  one  posture  he  is  more  liable  to  suffer  than  in 
another.  When  the  tumour  has  attained  a  certain  magnitude  there 
is  dulness,  not  perceptible  on  gentle  percussion,  but  brought  out  by 
a  firm  stroke,  most  marked  near  the  sternum,  and  not  to  be  detected 
in  the  axilla,  or  towards  the  side  of  the  chest.  The  breathing  is 
generally  weaker,  with  prolonged  expiration,  heard  at  a  distance ; 
the  sounds  of  the  heart  are  transmitted  loudly  over  the  seat  of  the 
tumour,  and  even  beyond  it.  The  patient  perhaps  breathes  in  a 
wheezing  manner  with  considerable  labour,  or  the  respiration  may 
be  obstructed  to  nearly  the  same  extent  as  it  is  in  laryngitis;  the 


TUMOURS.  261 

cough  is  often  weak  and  powerless,  like  that  of  emphysema,  but  has 
more  of  a  paroxysmal  character,  and  sometimes  a  loud  brassy  clang: 
a  fit  of  coughing  very  generally  terminates  with  a  raucous  inspira- 
tion. In  many  of  these  respects  the  analogy  to  laryngitis  is  very 
striking,  and  the  most  marked  difference  between  the  two  is,  that 
when  the  obstruction  is  in  the  larynx  itself,  the  voice  is  either 
hoarse  or  destroyed,  while  when  it  is  lower  down  in  the  trachea,  the 
voice  is  scarcely  altered  in  tone;  it  is  only  deficient  in  force. 

The  interruption  to  the  circulation  caused  by  the  tumour  may  at 
once  lead  us  to  infer  its  existence:  it  presses  upon,  or  even  sur- 
rounds and  encloses  the  superior  vena  cava,  in  consequence  of 
which,  tortuous  veins  begin  to  develop  themselves  over  the  chest 
and  abdomen,  and  the  blood  finds  its  way  by  a  backward  current 
into  some  pervious  channel;  sooner  or  later  this  venous  obstruction 
gives  rise  to  oedema,  which  is  theaJimited,  in  a  remarkable  manner, 
to  the  upper  half  of  the  body.  This  happens  both  with  malignant 
growth  and  with  aneurism ;  in  the  latter  case  additional  signs  are 
sometimes  derived  from  the  arterial  circulation:  the  force  of  the 
current  is  diminished  in  some  one  or  more  of  the  arteries,  causing 
perhaps  a  notable  difference  between  the  two  radials  at  the  wrist; 
or  both  alike  to  be  almost  imperceptible,  while  the  heart's  action  is 
very  generally,  but  not  always,  increased:  a  bruit  may  be  heard  in 
some  unusual  part  of  the  chest,  while  there  is  none  at  the  heart,  or 
it  may  be  heard  loudly  at  both,  and  be  almost  inaudible  at  interme- 
diate points.  Sometimes,  again,  the  ordinary  systole  of  the  heart 
is  heard  unusually  loud  at  some  particular  point,  and  this  may  be 
regarded  as  the  effect  of  aneurism,  because  the  sound  has  a  knock- 
ing or  jogging  character,  which  is  only  preliminary  to  a  similar 
impulse  being  felt,  when  the  disease  has  approached  nearer  to  the 
surface. 

Sooner  or  later  aneurism  shows  itself  externally  by  wearing  away 
the  ribs,  and  forming  a  pulsating  tumour  on  the  front  of  the  chest, 
or  by  pulsation,  which  can  be  felt  when  the  finger  is  pressed  deeply 
behind  the  sternum  or  clavicle,  except  in  the  case  of  the  descending 
aorta,  when  it  sometimes  produces  no  symptoms  upon  which  reliance 
can  be  placed:  slight  dysphagia  or  dyspnoea,  with  pain  in  the  back, 
caused  by  pressure  and  wasting  of  the  vertebrae,  sometimes  leading 
to  paralysis,  maybe  the  only  symptoms:  no  bruit  is  usually  audible 
in  this  situation ;  but  would  be  of  considerable  significance  if  heard 
in  an  adult;  in  the  child,  cardiac  murmurs  are  often  very  loud  over 
the  back.  Solid  tumours  in  the  chest  do  not  often  pulsate,  but  the 
possibility  of  pulsation  being  only  communicated  should  be  borne 
in  mind  in  attempting  to  discriminate  their  character. 

Tumours  in  connexion  with  the  bones  of  the  chest  seldom  give 
rise  to  any  symptoms  likely  to  call  for  examination,  until  there  is 
swelling  externally:  those  forming  in  the  anterior  mediastinum, 
which  cannot  find  exit  from  the  chest,  and  press  inwards  on  the 
heart,  the  arteries,  the  veins,  and  the  bronchi,  do  however  produce 


262  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

symptoms  more  or  less  resembling  those  of  pressure  on  the  root  of 
tne  lnng.  The  very  marked  dulncss  which  they  cause  on  percussing 
the  sternum  leads  at  once  to  the  recognition  of  their  presence;  and 
tlic  question  is  then  only  between  enlarged  heart  or  aneurism,  and 
growth  from  bone. 

The  coexistence  of  active  pleurisy,  or  of  passive  effusion  into 
either  pleura,  sometimes  greatly  complicates  the  diagnosis  of  tho- 
racio  tumours. 

§  11.  Hooping-cough.  As  in  many  other  diseases  in  -which  the 
group  of  symptoms  is  better  known  than  the  nature  of  the  internal 
lesion,  hooping-cough,  when  well  marked,  cannot  be  mistaken;  and 
diagnosis  has  only  to  do  with  those  cases  which  are  obscure,  because 
the  whoop  is  imperfectly  developed,  or  because  the  disease  is  si- 
mulated by  or  complicated  with  iher  affections.  Simple  catarrh  of 
childhood  may  very  readily  pass  into  hooping-cough  if  it  be  at  the 
time  prevailing  epidemically;  and  this  is  the  more  probable  when 
the  cough  is  at  all  paroxysmal,  or  is  an  urgent  or  an  early  symptom, 
and  when  the  fever  is  slight,  and  there  is  but  little  derangement  of 
health,  and  especially  when  auscultation  fails  in  detecting  bronchial 
irritation  proportionate  to  the  severity  of  the  cough. — When  the 
disease  is  fully  formed,  if  a  paroxysm  occur  in  our  presence  the  case 
can  scarcely  be  mistaken ;  but  we  must  often  trust  to  the  report  of 
others;  and  there  is  a  tendency  to  error  in  listening  to  the  state- 
ments of  mothers  and  nurses,  who  usually  anticipate  us  in  the  con- 
jecture of  its  possible  presence,  and  are  disposed  at  once  to  attribute 
any  peculiarity  in  the  child's  cough  to  this  cause.  A  very  good 
indication  is  obtained  in  cases  where  the  account  of  the  paroxysm 
is  defective,  from  the  occurrence  of  vomiting:  a  child  with  this  dis- 
ease often  vomits  after  a  fit  of  coughing,  while  in  other  affections  of 
the  chest  such  an  occurrence  is  purely  accidental;  in  the  one  it  is 
brought  on  simply  by  the  cough,  without  sickness  or  loss  of  appetite, 
and  the  child  will  take  his  food  directly  afterwards:  in  the  other, 
the  stomach  and  bowels  are  disordered,  and  the  relation  to  the 
cough  is  far  less  evident. 

In  the  early  period  of  an  attack  of  alleged  hooping-cough,  the  pre- 
sence of  much  bronchial  secretion  should  make  us  cautious  in  ac- 
cepting the  statement  of  the  friends  as  to  the  nature  of  the  disorder ; 
similar  caution  is  necessary  when  the  disease  is  said  to  have  attacked 
a  child  who  has  been  long  suffering  from  cough  before  any  thing  like 
a  whoop  was  observed.  In  its  latter  stages  there  is  usually  much 
bronchial  secretion,  and  the  disease  is  frequently  complicated  by 
inflammation  of  the  lung  or  effusion  into  the  ventricles  of  the  brain  ; 
in  very  protracted  cases  it  may  terminate  in  the  development  of 
tubercle:  diagnosis  must  then  take  account  not  only  of  the  present 
symptoms,  but  of  the  history  at  a  time  when  the  characters  of  the 
affection  were  simple  and  unmixed  with  those  of  subsequent  com- 
plications.    An  ill-developed  child  in  whom  an  attack  of  bronchitis 


DISEASES    OF   THE   LUNGS    IN   CHILDHOOD.  263 

is  attended  with,  excessive  secretion,  or  one  whose  lungs  are  be- 
coming stuffed  with  tubercles,  when  the  secretion  is  scanty  and 
adhesive,  are  each  of  them  very  liable  to  fits  of  coughing,  in  which, 
while  there  is  no  real  whoop,  the  struggle  for  breath  is  very  ana- 
logous to  the  abortive  paroxysms  which  occur  before  hooping- 
cough  is  fully  developed. 

§  12.  Diseases  of  the  Lungs  in  Childhood. — This  chapter  would 
be  "incomplete  if  a  few  words  were  not  said  upon  the  differences  in 
diagnosis  between  the  diseases  of- children  and  those  of  adults.  In 
the^first  place,  the  resiliency  of  the  chest  makes  the  indications 
from  percussion  much  more  obscure  and  uncertain;  at  one  time 
dulness  seems  to  be  well  marked,  which,  after  all,  is  only  due  to 
congestion ;  at  another,  real  consolidation  produces  only  a  difference 
in  tone,  which  cannot  properly  be  called  dull.  Secondly,  the  re- 
spiratory sound  is  so  much  louder  and  shriller,,  that  changes  in 
character,  except  in  its  relative  suppression,  cannot  be  predicated  of 
it  with  anything  like  the  same  certainty  as  in  adults.  Thirdly,  the 
loudness  of  the  voice  does  not  assist  us  much  in  determining  the 
sound-conducting  power,  and  hence  the  degree  of  consolidation  of 
the  lung.  And  fourthly,  the  remark  in  regard  to  superadded  spunds 
in  adults,  that  no  one  is  pathognomonic  of  any  certain  condition  of 
lung,  is  infinitely  more  true  of  children.  Crepitation  in  its  true 
sense  is  not  heard  in  pneumonia,  clicking  and  squeaking  sounds  are 
heard  when  there  are  no  tubercles,  and  gurgling  noises  are  heard 
without  cavitfes.  The  explanation  of  all  these  circumstances  is 
simply  that  in  the  lungs  of  the  child  evejy  sound  generated  any 
where  throughout  the  lungs  is  heard  with  almost  equal  distinctness  at 
any  part  of  the  surface ;  and,  therefore,  whatever  the  affection  may 
be  the  bronchial  sounds  prevail:  at  the  same  time  the  mucousmem- 
brane  is  more  easily  irritated,  and  secretion  excited  by  slighter 
causes ;  and  hence  it  happens  that  sonorous  sounds  are  very  seldom 
present. 

In  the  diagnosis  of  the  diseases  of  childhood  we  are  therefore 
very  dependent  upon  the  history  of  the  case  and  the  amount  of 
febrile  disturbance ;  but  it  must  be  remembered  that  the  quick  cir- 
culation of  childhood  is  much  more  readily  excited  than  that  of  the 
adult,  and  the  comparison  must  not  be  made  between  the  pulse  of 
infancy  and  that  of  age,  in  coming  to  the  conclusion  that  a  child  is 
suffering  from  inflammation  of  the  lungs.  That  this  is  constantly 
done  there  can  be  no  doubt,  from  the  frequency  with  which  mothers 
report  that  children  have  had  such  attacks,  and  that  they  have  been 
told  so  by  their  medical  attendant.  Inflammation  of  the  chest, 
whether  as  pleurisy  or  pneumonia,  is  not  by  any  means  a  frequent 
ailment  of  childhood — pleurisy  is  especially  rare  in  the  first  years 
of  life,  and  when  pneumonia  is  present  its  symptoms  are  invariably 
urgent.  If  any  thing  be  needed  in  the  way  of  auscultation  to  con- 
firm the  diagnosis  (and  it  is  always  wise  to  practise  it,)  we  find  per- 


2G4  DISEASES    OF    TIIE    RESPIRATORY    ORGANS. 

haps  some  difference  in  tone  on  percussion  between  the  two  sides 
of  the  chest,  or  it  may  be,  absolute  dulness;  the  breathing  probably 
differs  on  the  two  sides,  and  we  may  be  able  to  say  that  one  is 
harsher  than  the  other, — more  commonly,  however,  it  is  only  less 
distinct  on  the  affected  side,  and  then,  in  place  of  crepitation,  we 
find  moist  sounds;  or  at  all  events  very  coarse  crepitation, — never 
the  fine  sound  heard  in  the  adult.  Along  with  this  there  may  be 
very  considerable  bronchial  irritation  of  the  other  lung,  so  that  all 
the  signs  of  disease  may  be  suspected  to  be  due  to  bronchitis,  and 
in  fact  the  cases  are  quite  exceptional  in  which  unaided  auscultation 
could  determine  the  nature  of  the  affection. 

Bronchitis  occurs  either  as  acute  or  chronic.  In  the  former  the 
sonorous  sounds  are  very  rarely  heard ;  there  is  a  good  deal  of  fever, 
but  it  is  not  so  severe  as  that  of  pneumonia,  the  skin  is  not  so  pun- 
gent, and  the  signs  of  imperfect  aeration  of  the  blood  are  not  pre- 
sent: the  breathing  is  louder  or  weaker,  according  to  the  amount 
of  secretion  present,  and  this  often  differs  on  the  two  sides.  The 
principal  indication  derived  from  auscultation  is  the  very  general 
distribution  of  the  morbid  sounds ;  the  absence  of  any  difference  in 
percussion  would  confirm  the  impression  that  the  disease  was  simply 
bronchitis,  but  dulness  on  one  side  behind  must  not  be  taken  as  a 
proof  that  pneumonia  is  present;  not  only  may  an  appearance  of 
dulness  be  produced  by  mere  congestion,  but  the  existence  of  tuber- 
cular glands  at  the  root  of  one  lung  which  may  have  tended  to  excite 
the  bronchitis  may  also  be  the  cause  of  absolute  dulness. 

Chronic  bronchitis,  which  so  often  simulates,  or  is  simulated  by 
phthisis  in  the  adult,  is  often  quite  undistinguishable  from  tuber- 
cular disease  in  infancy.  Here  dissemination  of  tubercle  is  the 
rule ;  its  aggregation  in  masses,  except  in  the  bronchial  glands,  the 
exception.  It  is  from  the  aspect  of  the  child  and  the  history  of 
the  case  alone  that  we  can  judge,  aided  probably  in  some  measure 
by  the  general  symptoms,  and  occasionally  by  the  character  of  the 
sputa.  When  we  learn  that  the  patient  has  had  an  attack  of 
measles,  or  has  suffered  much  during  dentition — that  the  constitu- 
tion has  not  rallied,  but  cough  has  gradually  supervened;  when 
there  is  a  pallid,  transparent  skin,  with  long  eyelashes  and  brilliant 
eyes,  and  the  child  is  peevish  and  irritable,  or  languid  and  unex- 
citable,  or  remarkably  quick  and  intelligent — suspicions  of  tubercle 
are  naturally  excited:  and  if  in  addition  to  this  we  find  emaciation, 
debility,  heat  of  skin,  followed  by  perspiration  and  diarrhoea,  the 
probabilities  are  greatly  increased.  If,  on  the  contrary,  we  learn 
that  the  first  attack  was  feverish,  or  that  after  hooping-cough,  some 
years  before,  there  has  been  great  liability  to  coughs  and  colds;  if 
the  face  be  dusky,  or  the  lips  discoloured,  and,  except  from  dread 
of  an  impending  cough,  the  child's  temper  be  not  materially  altered; 
if,  in  addition  to  this,  we  learn  that  the  cough  ends  in  copious  ex- 
pectoration, even  though  that  should  be  tinged  with  blood, — the 
diagnosis  and  the  prognosis  are  considerably  more  favourable:  has- 


DISEASES    OP   THE   LUNGS   IN   CHILDHOOD.  265 

moptysis  in  childhood  is  by  no  means  a  sign  of  phthisis.  The  ste- 
thoscope can  scarcely  afford  any  assistance  in  discriminating  these 
affections:  and  it  must  be  added  that,  when  judicious  treatment  is 
employed  in  cases  -which  have  all  the  aspect  of  tubercle,  the  chil- 
dren so  completely  recover  from  the  attack  of  bronchial  irritation 
accompanying  it,  and  are  so  often  lost  sight  of  subsequently,  that 
no  person  of  any  experience  will  venture  to  give  a  decided  opinion 
except  in  very  clearly  marked  examples  of  each  disease.  It  is  to 
be  remembered  that  when  the  bronchial  affection  has  passed,  the 
sio-ns  of  remaining  consolidation  at  the  apex  are  never  found  in 
childhood ;  if  any  localization  of  tubercle  prevail  at  this  period  of 
life,  it  is  only  in  the  glands  at  the  root  of  the  lungs. 


2GG 


CHAPTER  XXI. 

EXAMINATION    OF   TIIE    HEART. 

History  and  General  Symptoms — Changes  independent  of  Disease — 
Special  Signs. 

Div.  I. — Evidence  of  Alteration  in  Size — Increased  Impulse — Irre- 
gular Action — Extended  Dulness — their  Mutual  Relations. 

Div.  II. — Auscultatory  Phenomena. — §  1,  Modifications  of  Normal 
Sounds — in  Intensity — in  Distinctness — in  Rhythm — §  2,  J 
Hon — its  Characters — its  Indications — §  3,  Endocardial  Mur- 
murs— their  general  Characters  (a)  Diastolic — Aortic — Mitral — 
(b)  Systolic — (1)  at  the  Apex — Mitral — Tricuspid — (2)  at  the 
Base — Aortic — Pulmonic — Blood-sounds  in  general. 

In  Chapter  XVII.,  when  considering  the  history  and  general 
symptoms  of  disease  of  the  chest,  it  was  remarked  that  dyspnoea 
and  palpitation  are  the  chief  subjects  of  complaint  with  patients 
suffering  from  disturbance  of  the  circulation,  and  that  the  history 
of  the  attack  is  usually  obscure  and  imperfect.  It  may  be  added 
that  these  symptoms  are  much  more  frequently  mentioned  when 
their  cause  is  merely  functional  than  when  organic  lesion  exists. 
Pain  is  an  almost  constant  attendant  on  pericardial  inflammation: 
it  is  also  occasionally  met  with  in  old  structural  changes,  presenting 
itself  sometimes  under  the  form  of  angina.  A  history  of  rheumatic 
fever,  any  indications  of  a  tendency  to  dropsy,  or  the  presence  of 
chronic  lung  affection,  and  especially  of  bronchorrhoea,  are  each  of 
them  more  or  less  valuable  in  estimating  the  probability  of  disease 
of  the  heart.  In  most  instances,  however,  its  presence  may  be 
very  conclusively  shown  by  the  action  of  the  pulse,  the  discoloration 
of  the  face,  the  impulse  against  the  ribs  which  accompanies  the 
movement  of  the  organ,  and  the  characters  of  the  sounds  produced, 
as  they  are  changed  by  specific  forms  of  disease.  Errors  in  diag- 
nosis chiefly  arise  from  confounding  the  signs  of  the  functional 
with  those  of  the  structural  maladies. 

We  must  presume  that  the  student  is  familiar  with  the  position 
and  average  force  of  the  impulse  which  each  stroke  of  the  heart 
conveys  to  the  fingers  placed  between  the  fifth  and  sixth  rib;  with 
the  usual  extent  of  dulness  on  percussion  observed  in  the  precordial 
region,  when  it  is  of  normal  size;  and  with  the  sounds  which  accom- 
pany its  systole  and  diastole  in  a  state  of  health,  hence  called  sys- 
tolic and  diastolic,  or  first  and  second  sounds.  In  each  of  these 
particulars,  changes  may  be  perceived  which  are  quite  independent 
of  disease  of  the  heart:  its  position  may  be  altered  by  effusion  into 
the  pleura  or  peritoneum:  its  impulse  may  be  rendered  more  evi- 


EXAMINATION    OF   THE   HEART.  267 

dent  by  emaciation,  or  by  consolidation  of  the  lung,  or  may  be  les- 
sened by  opposite  states:  the  sharpness  and  force  of  the  shock  may 
be  greatly  increased  by  mere  nervous  excitement:  and  the  precor- 
dial dulness  may  be  diminished  or  increased  in  extent,  as  it  hap- 
pens to  be  more  or  less  covered  by  resonant  pulmonary  tissue. 

Nervous  palpitation  without  increase  of  size  of  the  heart  itself, 
will  be  observed  to  vary  much  in  intensity  from  time  to  time,  and 
this  especially  according  to  the  mental  condition,  whether  of  ex- 
citement or  of  depression.  Attention  directed  to  the  organ  greatly 
influences  it,  and  not  unfrequently  the  fact  of  making  the  exami- 
nation is  of  itself  sufficient  to  excite  or  increase  the  palpitation, 
which  again  gradually  subsides :  this  condition  is  one  which  attracts 
the  patient's  notice  much  more  than  palpitation  depending  on  real 
disease. 

Division  I. — Evidence  of  Alteration  in  Size. 

Those  deviations  from  the  normal  conditions  which  afford  the 
most  certain  indications  of  changes  in  the  dimensions  of  the  heart, 
and  ought  therefore  to  be  especially  studied  by  the  learner,  are  the 
following: — When  the  heart  beats  lower  down  than  in  health ;  when 
the  usual  shock  of  its  impinging  on  the  parietes  becomes  diffuse, 
heaving,  undulatory,  or  irregular;  when  the  dulness  on  percussion 
is  extended  in  an  inward  or  an  upward  direction;  and  when  the 
stethoscope  reveals  sounds  which  are  not  heard  under  ordinary  cir- 
cumstances. 

"With  the  exception  of  the  stethoscopic  signs,  all  of  these  derive 
their  value  from  their  affording  the  most  conclusive  evidence  which 
we  possess  of  changes  of  size  in  the  organ;  and  this  consideration 
ouo-ht  always  to  be  taken  into  account  in  making  a  diagnosis  of 
disease  of  the  heart.  For  no  important  deviation  from  health  can 
long  persist  without  affecting  the  muscular  structure;  and  altera- 
tions in  thickness,  in  capacity,  and  in  power  are  those  which  are 
really  efficient  in  developing  the  secondary  affections  accompanying 
the  advanced  stages  of  disease. 

1.  Its  impulse  being  felt  at  a  lower  point  than  usual,  is  almost  a 
certain  sign  of  enlargement. 

2.  WThen  the  action  is  heaving  and  powerful,  lifting  up  the  stetho- 
scope, or  even  the  head  of  the  listener,  at  each  impulse,  the  walls 
must  necessarily  be  thickened:  in  such  cases  the  sharpness  of  the 
stroke  is  lost,  and  its  duration  prolonged.  In  other  instances  the 
impulse  is  much  more  diffuse,  and  less  forcible,  the  heart  coming  in 
contact  with  different  portions  of  the  chest  at  successive  intervals 
during  the  prolonged  systole,  with  an  undulatory  movement,  in 
which  no  distinct  stroke  is  felt:  we  have  then  reason  to  believe 
that  the  enlargement  depends  more  on  increased  size  of  the  cavi- 
ties than  on  thickening  of  its  walls. 

3.  Irregularity  of  action  is  very  important,  although  of  some- 
what indefinite  signification.     It  must  not  be  confounded  with  in- 


208  EXAMINATION    OF   THE   HEART. 

termission  when  a  single  beat  is  occasionally  omitted  or  abortive,  or 
a  short  pause  occurs  at  certain  intervals.  Continued  irregularity 
must  be  regarded  as  a  positive  sign  of  disease,  but  it  may  co-exist 
with  almost  any  form  of  lesion.  It  is  probably  most  frequently 
met  with  in  disease  of  the  mitral  valve. 

•1.  The  extension  of  dulness  towards  the  sternum  derives  its 
value  from  the  circumstance  that  there  the  heart  is  uncovered  by 
lung,  and  the  liability  to  inaccuracy  is  not  so  great  as  when  an  at- 
tempt is  made  to  measure  it  outwards.  In  enlargement  of  the 
heart  the  percussion  dulness  is,  no  doubt,  extended  in  every  direc- 
tion, and  a  practitioner  well  versed  in  the  physical  aids  to  diagnosis 
would  be  able  to  detect  the  exact  dimensions  of  the  organ,  in  spite 
of  the  interposition  of  resonant  lung-tissue:  the  student  cannot 
expect  to  do  so  with  accuracy.  In  an  upward  direction  diminished 
resonance  may  be  distinguished  with  tolerable  readiness;  but  when 
the  sound  is  clear  over  the  sternum  it  is  probably  due  to  some  other 
cause  than  hypertrophy:  it  is,  for  example,  especially  marked  in 
distention  of  the  pericardial  sac  after  pericarditis. 

5.  In  connexion  with  the  preceding  indications,  the  stethoscopic 
signs  are  most  valuable  in  explaining  the  causes  of  increased  or 
irregular  action,  because  the  abnormal  sounds  are  produced  by  ac- 
tual changes  in  the  relation  of  solids  and  fluids,  and  enable  us  to 
assert  more  or  less  positively  what  is  the  nature  of  that  change. 

_  The  altered  position  of  the  impulse  may  possibly  be  clue  to  an  adherent  pericar- 
dium; but  in  this  case  there  is  very  generally  also  hypertrophy,  and  the  idea  of 
enlargement  is  probably  correct.  If  it  can  be  shown  that  there  is  no  enlargement, 
this  alteration  of  the  impulse  affords  the  most  reliable  evidence  of  pericardial  ad- 
hesion, which  after  all  can  only  be  guessed  at. 

There  ought  to  be  no  difficulty  in  distinguishing  the  heaving  impulse  of  hyper- 
trophy from  the  short,  sharp  stroke  of  nervous  palpitation;  and  yet  in  very  many 
instances  people  are  told  that  they  have  disease  of  the  heart  in  consequence  of  the 
one  being  mistaken  for  the  other. 

^  Undulatory  movement,  in  strict  language,  is  only  produced  when  the  pericar- 
dium is  full  of  serum;  a  largely  dilated  heart  merely  simulates  it:  in  the  one  a 
wave  is  transmitted  from  the  apex  towards  the  distended  upper  extremity  of  the 
sac,  at  each  systole;  in  the  other,  different  portions  of  the  organ  come  in  contact 
with  the  chest  in  succession,  but  the  definite  course  of  a  wave  cannot  be  traced; 
the  one  occurs  during  an  acute  attack,  the  other  is  seen  in  chronic  disease. 

Irregularity  is  best  recognised  by  the  action  of  the  pulse:  by  it  the  meaning  of 
the  term  intermission  is  also  more  readily  understood;  the  abortive  contraction  of 
the  heart  produces  no  pulsation  at  the  wrist,  and  a  beat  is  lost  just  as  much  as  if 
the  heart  stood  still.  The  word  "uneven"  is  used  to  signify  a  pulse  of  unequal 
force:  an  irregular  pulse  implies  inequality  in  the  duration  as  well  as  in  the  force 
of  successive  beats.  Irregular  action  may  subside  under  treatment,  but  during  its 
existence  it  is  a  permanent,  not  a  temporary  condition;  hence  we  speak  of  con- 
tinued irregularity  as  a  sign  of  disease. 

The  extension  of  dulness  towards  the  sternum  can  only  deceive  when  there  is  a 
morbid  growth  in  the  anterior  mediastinum:  the  dulness  in  such  a  case  does  not 
usually  terminate  on  a  level  with  the  base  of  the  heart.  It  is  of  importance  to 
observe  whether  the  apex  continue  to  beat  in  its  usual  position,  lest  displacement* 
be  mistaken  for  enlargement. 

In  endeavouring  to  establish  correct  rules  for  diagnosis,  it  has 


ALTERATION    IN    SIZE.  269 

• 

been  our  constant  aim  to  avoid  taking  solitary  indications,  however 
definite  in  themselves,  as  specific  signs  of  any  one  form  of  disease. 
This  rule  must  be  applied  to  the  varieties  of  pulse  observed  in  dis- 
ease of  the  heart,  which  will  be  enumerated  as  they  present  them- 
selves to  our  notice  in  considering  the  sum  of  the  evidence  in  each 
case.  It  is  also  applicable  to  the  suggestion  of  adherent  pericar- 
dium above  referred  to,  and  to  the  angular  or  pear-shape  which  we 
may  find  the  precordial  dulness  to  have  assumed  when  dependent 
on  hydro-pericardium;  no  one  who  studies  diagnosis  aright  will 
suppose  the  existence  of  such  a  condition,  unless  acute  symptoms 
have  preceded  it;  passive  effusion  is  never  sufficiently  extensive  to 
produce  the  effect. 

If  we  commence  with  irregularity  of  action  as  one  of  the  most 
evident  signs  of  disease,  we  find  in  practice  that  it  may  coincide 
with  the  other  phenomena  already  enumerated  in  very  varying  de- 
grees, and  from  a  consideration  of  these  associations  the  following 
conclusions  may  be  drawn  as  probable  explanations  of  the  condition 
of  the  heart. 

a.  With  increased  heaving  impulse,  we  may  assume  the  existence 
of  hypertrophy  with  or  without  valvular  lesion. 

b.  Without  increased  impulse,  but  with  extended  dulness,  enlarge- 
ment consisting  especially  in  dilatation  of  the  cavities,  while  the 
walls  are  not  much  thickened,  or  may  be  even  thinner  than  natu- 
ral; and  again  either  with  or  without  valvular  lesion. 

c.  When  abnormal  sound  is  heard,  we  may  be  pretty  certain  that 
there  is  valvular  insufficiency  along  with  either  hypertrophy  or  dila- 
tation, as  the  other  indications  tend  to  show. 

d.  A  very  feeble  pulse,  with  signs  of  hypertrophy,  would  afford 
very  clear  evidence  of  imperfect  closure  of  the  mitral  valve. 

e.  When  none  of  these  conditions  accompany  the  irregularity, 
we  may  be  led  to  believe  that  it  is  due  to  thinning  of  the  walls  or 
fatty  degeneration  without  dilatation  to  any  extent :  it  may  possibly 
be  also  caused  by  adherent  pericardium. 

Irregular  action  seldom  accompanies  hypertrophy  without  valvular  lesion ; 
whereas  it  is  most  commonly  present  in  dilatation  and  thinning  of  the  walls,  whe- 
ther the  valves  be  healthy  or  not.  The  character  of  the  pulse  varies  with  the  pe- 
culiar form  of  the  valvular  lesion,  but  in  most  instances  the  morbid  sound  heard 
on  auscultation  is  more  trustworthy :  it  now  and  then  happens,  however,  that  when 
the  mitral  orifice  does  not  close  during  the  systole,  no  bruit  can  be  detected;  and 
then  the  extreme  feebleness  of  the  pulse  contrasting  with  the  force  of  the  heart's 
action,  serves  as  a  very  useful  guide.  When  valvular  lesion  has  not  led  to  altera- 
tion in  size,  it  is  not  accompanied  by  irregularity  of  action. 

It  must  also  be  borne  in  mind  that  very  considerable  hypertrophy  may  be  al- 
most completely  concealed  by  over-lapping  of  the  lung,  and  therefore  great  cau- 
tion must  be  exercised  in  deciding  that  irregular  action  depends  on  simple  atrophy 
or  fatty  degeneration.  Each  of  these  subjects  will  be  again  referred  to  more  in 
detail. 

When  there  is  no  irregularity  the  only  trustworthy  indications  of 
enlargement  are — 

a.  If  increased  action  be  associated  either  with  extension  of 


270  EXAMINATION    OF    THE    HEART. 

• 

dulness  in  an  inward  direction  or  with  an  apex-bea?  lower  than  in 
health ; 

b.  If  with  the  increased  action  or  the  extended  dulness  there  be 
any  thing  of  an  undulatory  movement,  and  especially  if  this  be  ac- 
companied by  some  unusual  sound  on  auscultation. 

Division  II. — Auscultatory  ^Phenomena. 

In  very  many  instances  these  alone  are  sufficient  to  determine  the 
existence  of  disease  in  an  early  stage,  before  any  change  has  oc- 
curred in  the  actual  dimensions  of  the  organ;  in  other  instances 
they  explain  the  cause  of  the  change.  They  may  be  divided  into 
modifications  of  normal  sounds,  and  morbid  sounds — "bruits"  or 
"murmurs,"  as  it  seems  better  to  call  them  to  distinguish  them  from 
those  which,  par  excellence,  are  called  the  sowids  of  the  heart.  These 
bruits,  again,  comprise  those  formed  in  the  pericardium  and  those 
formed  within  the  heart,  sometimes  classed  as  exocardial,  and  endo- 
cardial: the  only  pericardial  bruit  is  friction;  the  endocardial,  on 
the  other  hand,  are  divisible  into  the  systolic  and  diastolic.  We 
shall  attempt  to  show  what  deductions  may  be  drawn  from  their 
presence,  and  how  the  student  may  best  refer  the  sound  heard  to 
one  or  other  of  these  classes. 

Much  confusion  is  created  by  unnecessarily  increasing  the  nomenclature  of  va- 
rious sounds.  It  is  quite  allowable  to  employ  a  particular  name  to  designate  any 
unusual  bruit,  such  as  "purring,"  or  "musical,"  but  its  exact  character  is  now 
known  to  be  of  far  less  importance  than  its  position  and  time  of  occurrence  with 
reference  to  the  rhythm  of  the  heart's  action.  It  seems  quite  unnecessary  to  in- 
troduce such  a  name  as  exocardial:  if  it  mean  to  include  sounds  formed  in  the 
pleura,  and  not  in  the  pericardium,  the  classification  is  objectionable :  if  it  be  re- 
stricted to  the  pericardial  bruit,  we  need  employ  no  other  name  than  friction ; 
creaking  is  but  a  form  of  friction,  and  the  name  "to  and  fro"  sound  which  has 
been  sometimes  used,  is  only  applicable  to  certain  cases,  a  majority,  truly,  but  not 
all.  With  regard  to  endocardial  murmurs,  again,  the  introduction  of  the  word  re- 
gurgitant perplexes  the  student:  either  a  systolic  or  a  diastolic  bruit  may  be  re- 
gurgitant; and  regurgitation  may  take  place  at  any  of  the  sets  of  valves;  it  merely 
expresses  the  fact  of  the  ordinary  current  being  reversed, — a  fact  which  is  quite 
as  explicitly  stated  when  the  bruit  is  named  according  to  its  time  and  place.  If 
during  the  diastole  the  left  ventricle  be  filled  from  the  aorta  as  well  as  from  the 
auricle,  there  is  regurgitation;  if  during  the  systole  the  blood  pass  out  into  the 
auricle  as  well  as  iuto  the  aorta,  there  is  also  regurgitation;  but  any  one  who  un- 
derstands the  mechanism  of  the  heart's  action  knows  that  the  expressions  diastolic 
aortic,  and  systolic  mitral  murmurs  imply  these  facts,  and  have  the  great  advan- 
tage of  being  definite  statements  regarding  disease. 

§  1.  Modifications  of  Normal  Sounds. 

a.  They  may  have  a  ringing  distinctness  in  consequence  of  ner- 
vous excitement:  this  is  no  indication  of  disease;  it  is  transient, 
and  when  the  palpitation  subsides,  the  sounds  resume  their  ordinary 
characters. 

b.  The  1st  sound  especially  tends  to  become  short  and  sharp  in 
thinning  of  the  walls  of  the  heart:  the  chief  distinction  between 
this  and  the  preceding  condition  is  its  permanence,  and  its  inde- 
pendence of  excitement  and  palpitation. 


CHANGES  IN  NORMAL  SOUNDS.  271 

c.  They  become  dull  and  indistinct,  though  loud,  in  hypertrophy. 
The  prolongation  and  indistinctness  of  the  1st  sound  in  particular, 
is  the  reason  why  they  are  often  spoken  of  as  being  weaker  than 
the  sharp  flapping  sound  of  dilatation. 

d.  Distance  and  obscurity  of  sound  is  produced  by  the  interpo- 
sition of  fluid  in  the  pe/icardiuin  or  overlapping  of  the  lung,  espe- 
cially in  emphysema. 

e.  The  rhythm,  or  proportionate  duration  of  each  sound,  is  very 
liable  to  be  altered  in  the  commencement  of  an  inflammatory  at- 
tack: this  condition  is  very  generally  the  precursor  of  some  more 
definite  evidence  of  change  of  structure;  but  it  is  associated  with 
other  forms  of  disease,  and  is  also  occasionally  casual  and  transi- 
tory, the  sounds  returning  to  those  of  health. 

/.  Either  1st  or  2nd  sound  may  be  reduplicated.  Each  stroke  of 
the  pulse  is  represented  by  three  or  even  four  sounds  heard  in  the 
precordial  region.  It  is  generally  the  2nd  sound  which  is  redupli- 
cated, the  3rd  following  close  upon  it,  and  occupying  the  pause 
which  in  health  intervenes  between  the  end  of  the  2nd  and  the 
commencement  of  the  1st  sound.  When  the  1st  sound  is  redupli- 
cated, it  causes  of  necessity  reduplication  of  the  2nd.  This  modi- 
fication does  not  always  imply  disease:  it  seems  to  be  due  to  irre- 
gular muscular  action,  and  we  can  only  decide  from  other  circum- 
stances whether  the  defect  be  in  the  muscle  itself,  in  the  nervous 
system,  or  in  the  mechanism  of  the  circulation. 

The  most  important  of  the  modifications  just  enumerated  is  that  in  -which  the 
rhvthm  of  the  sounds  materially  deviates  from  that  in  health.  The  relative  dura- 
tion of  each  sound  and  of  each  pause  is  in  the  normal  state  so  constant,  that  it 
may  be  assumed  with,  great  confidence  that  disease  is  present  when  this  relation 
is  broken  through.  It  is  therefore  of  very  great  value  in  leading  us  either  to  dis- 
cover past  changes  in  structure,  of  which  the  evidence  is  imperfect,  or  to  prepare 
for  impending  inflammation:  it  may  thus  lead  to  the  discovery  of  an  endocardial 
murmur  which  was  not  suspected,  or  may  be  the  only  proof  left  that  pericarditis 
has  preceded  when  friction  is  already  abolished;  while  in  cases  of  acute  rheuma- 
tism, or  inflammation  in  the  chest,  it  prepares  us  for  an  attack  of  peri-  or  endo- 
carditis; and  in  those  cases  in  which  it  passes  off  without  any  furtherevidence  of 
disease,  we  are  left  to  conclude  that  our  remedies  have  aided  in  warding  off  very 
serious  mischief. 

The  loudness  of  the  sounds  depends  so  much  more  upon  the  proximity  of  the 
heart  to  the  chest-wall  than  upon  the  intensity  of  the  sound  itself,  that  but  little 
reliance  is  to  be  placed  on  it  as  an  indication:  and  perhaps  in  no  case  is  it  so 
marked  as' in  the  palpitation  of  nervous  excitement.  The  very  same  circumstance 
which  most  frequently  serves  to  conceal  the  dulness,  and  increased  impulse  in 
hypertrophy,  serves  also  to  diminish  the  loudness  of  the  sound;  and  therefore, 
when  much  overlapped  by  the  lung,  the  one  source  of  information  does  not  help 
to  correct  the  other.  Its  intensity  is  of  most  service  in  cases  of  nervous  palpita- 
tion, and  in  thinning  of  the  walls  of  the  heart  without  palpitation;  in  the  one  the 
shrillness  of  the  sound  is  opposed  to  the  idea  of  hypertrophy,  in  the  other  it  leads 
to  the  suspicion  of  change  of  structure,  which  is  not  revealed  by  any  other  sign. 

Reduplication,  like  intermission,  suggests  some  imperfection  in  the  relation  of 
nervous  force  and  muscular  contraction,  in  so  far  as  one  serves  to  regulate  the 
other:  but  while  we  were  able  to  draw  a  distinction  between  intermission  and  ir- 
regularity, as  indications  of  disease,  we  are  not  able  to  lay  down  the  same  certain 
rules  in  reduplication.     We  may  be  very  confident  that  when  both  sounds  are  re- 


■J.~-2  EXAMINATION    OF    T1IE    HEART. 

duplicated  there  ia  some  form  of  disease  present:  reduplication  of  the  2nd  sound 
is  very  often  caused  by  imperfect  closure  of  the  auriculo-ventricular  aperture  ou 

one  side,  which  causes  the  systole  of  one  ventricle  to  terminate  more  quickly  than 
the  other;  but  it  is  also  heard,  like  intermission,  in  what  we  call  mere  functional 
disturbance.  It  will  be  readily  understood  that  when  either  sound  becomes  pro- 
longed  by  the  presence  of  a  murmur,  the  reduplication  is  lost  in  the  continuous 
bruit,  li  is  wise  in  practice  to  restrict  the  term  reduplication  to  cases  in  which 
no  bruit  is  detected:  for  example,  when  there  is  a  slight  diastolic  aortic  murmur, 
the  2nd  sound  of  the  heart,  formed  at  the  pulmonic  valves,  may  be  heard  quite 
distinct  and  separate  from  the  aortic  bruit,  which  replaces  the  2nd  sound  there; 
but  the  two  do  not  consist  of  a  reduplicated  2nd  sound,  but  of  the  sound  and  the 
bruit,  which  are  heard  separately,  the  one  short  and  terminating  at  its  usual  time, 
the  other  prolonged. 

§  2.  Friction. — The  distinctive  character  of  this  sound  is  to  be 
sought  less  in  its  peculiar  acoustic  properties  than  in  the  time  of  its 
occurrence  with  reference  to  the  natural  sounds  of  the  heart.  It 
has  no  further  relation  to  them  than  that  it  is  caused  by  the  move- 
ment of  the  organ  consequent  on  its  alternate  contraction  and 
dilatation ;  hence  it  forms  no  part  of  the  natural  sounds,  does  not 
occur  at  the  same  instant,  does  not  follow  the  same  rhythm,  but  is 
usually  heard  somewhere  between  and  distinct  from  them.  The 
natural  sounds  may  be  inaudible  either  because  eifusion  renders 
them  indistinct,  or  because  the  friction  is  so  loud  as  to  overpower 
them,  but  it  neither  takes  their  place  nor  alters  their  character. 
Though  called  a  "to-and-fro"  sound,  it  is  not  necessarily  double, 
but  it  certainly  is  so  in  a  great  majority  of  cases.  Among  its  dis- 
tinguishing features  the  following  may  be  regarded  as  the  chief: — 

a.  It  may  be  heard  any  where  over  the  precordial  space,  and 
frequently  only  at  one  point  distinctly :  when  thus  circumscribed,  it 
is  especially  to  be  sought  either  where  the  membrane  is  reflected  at 
the  base  of  the  heart,  or  where  the  apex  impinges  against  the  ribs. 

b.  The  sound  is  usually  rough  and  grating,  and  seems  to  be  su- 
perficial and  close  to  the  ear  of  the  listener. 

c.  A  double  friction-sound  is  more  easily  recognised  than  when 
it  is  single :  endocardial  bruits  are  also  sometimes  double,  but  in 
the  to-and-fro  friction  the  duration  of  each  is  more  equal  and 
shorter. 

d.  The  time  of  its  occurrence  with  reference  to  the  natural 
sounds  forms  our  best  guide  in  determining  its  nature.  It  com- 
mences distinctly  after  the  1st  sound  and  impulse  of  the  heart;  the 
to-and-fro  friction-bruits  follow  each  other  rapidly  with  a  very  short 
interval,  which  corresponds  with  the  beginning  of  the  2nd  sound  of 
the  heart;  then  comes  a  longer  pause,  during  which  the  1st  sound 
is  again  heard,  followed  up  by  the  recurrence  of  friction. 

During  the  existence  of  pericarditis,  many  circumstances  occur  to  conceal  the 
ordinary  sounds  of  the  heart ;  and  when  there  is  any  difficulty  in  distinguishing 
them  in  the  precordial  space,  they  should  be  listened  for  above  the  base  of  the 
heart,  in  the  2d  intercostal  space. 

There  are  two  circumstances  which  chiefly  tend  to  render  friction-sound  liable 
to  be  confounded  with  other  bruits:  viz.,  a  scanty  secretion  of  lymph,  and  an 
abundant  secretion  of  serum.     The  friction  may  in  either  case  be  single;  in  the 


FRICTION.  273 

former  it  is  almost  always  limited  to  the  reflexion  of  the  pericardial  membrane  at 
the  origin  of  the  great  vessels,  and  might  therefore  be  taken  for  an  aortic  murmur; 
but  in  addition  to  the  indications  derived  from  the  other  characters  enumerated, 
it  is  especially  to  be  noted  that  its  position  and  point  of  greatest  distinctness  are 
below  and  not  above  the  base;  the  very  opposite  is  true  of  an  aortic  systolic  mur- 
mur, and  an  aortic  diastolic  murmur  presents  other  features  which  are  very  dis- 
tinctive. If  friction  be  obscured  by  the  presence  of  serum,  the  point  where  it  is 
most  likely  to  be  met  with  is  the  apex:  here  too  in  position  it  is  much  below  the 
ordinary  situation  of  a  mitral  murmur ;  but  it  is  further  to  be  recognised  by  the 
circumstance  that  it  is  much  louder  when  the  ribs  are  depressed  at  the  end  of  ex- 
piration, and  may  be  very  often  rendered  temporarily  so  by  simple  pressure. 

Friction  differs  from  endocardial  murmur  in  its  acoustic  properties  very  deci- 
dedly, when  a  well-marked  example  is  compared  with  the  pure  bellows-sound  :  and 
the  student  ought  to  make  his  ear  familiar  with  their  respective  characters;  but  in 
many  cases  he  must  be  prepared  to  find  each  approximate  so  closely  to  the  other 
that  the  character  of  the  sound  is  not  sufficient  to  denote  whether  it  be  formed  in 
the  heart  or  pericardium. 

The  best  mode  of  determining  whether  the  rhythm  of  a  double  bruit  heard  in 
the  precordial  space  differ  from  or  coincide  with  that  of  the  systole  and  diastole, 
is  to  listen  above  the  base  of  the  heart,  where  pericardial  friction  always  becomes 
inaudible:  when  the  ear  is  fully  accustomed  to  the  rhythm  of  1st  and  2nd  sounds 
as  there  heard,  the  stethoscope  should  be  immediately  passed  to  the  point  of  which 
the  bruit  is  most  distinct;  if  it  be  pericardial,  the  ear  will  at  once  detect  the  dif- 
ference in  duration,  and  the  want  of  harmony  with  that  just  listened  to. 

The  discovery  of  friction  may  be  taken  as  unmistakable  evidence 
of  the  presence  of  pericarditis,  and  hence  the  importance  of  being 
able  clearly  to  determine  its  true  character.  In  speaking  of  peri- 
carditis (Chapter  XXII.  §  1,)  the  ordinary  correlative  symptoms 
will  be  pointed  out;  and  while  on  the  one  hand,  these  may  be  so 
striking  as  to  leave  no  doubt  in  the  mind  of  the  observer  that  changes 
in  percussion  resonance,  or  in  the  rhythm  and  intensity  of  the  heart's 
action,  are  due  to  pericarditis  when  friction  cannot  be  detected, 
yet  on  the  other,  they  may  have  been  so  slight  that  but  for  the  pre- 
sence of  friction  we  should  not  know  of  the  existence  of  the  inflamma- 
tion at  all.  The  change  of  friction  into  creaking  is  far  less  common 
in  the  pericardium  than  in  the  pleura:  when  such  a  sound  is  heard, 
the  principles  of  its  dia'gnosis  are  the  same  as  those  already  given  for  a 
single  friction-bruit,  and  it  will  be  all  the  easier  because  of  its  creak- 
ing character,  which  is  so  unlike  an  endocardial  murmur.  There  is 
only  one  further  question  in  regard  to  friction  which  the  observer  has 
to  determine  in  order  that  his  diagnosis  of  pericarditis  may  be  quite 
certain;  it  is  that  the  friction  is  really  in  the  pericardium,  and  not 
in  the  adjacent  pleura.  Now,  the  only  chance  of  its  being  in  the 
pleura  is,  when  it  is  local — to  one  side  and  not  in  the  front  of  the 
heart ;  and  if  the  doubt  be  suggested  to  the  mind,  its  validity  can 
readily  be  tested  by  making  the  patient  hold  his  breath:  but  it  must 
be  remembered  that  pericardial  friction  becomes  more  distinct,  or 
may  be  only  audible  when  the  ribs  are  depressed,  and  therefore  the 
patient  should  be  taught  to  hold  his  breath  after  an  expiration,  not 
after  an  inspiration. 

§  3.  Endocardial  Murmurs. — Either  sound  of  the  heart  may  be 
prolonged  beyond  its  ordinary  duration,  and  lose  its  usual  distinct- 
18 


l274  EXAMINATION    OF    THE    IIEART. 

ncss  when  the  sound  is  commonly  called  rough:  they  may  be  entirely 
superseded  by  a  lengthened  bruit,  which  has  either  a  character  of 
extreme  softness  (the  true  bellows-murmur,  or  bruit  de  souffle,)  or 
that  of  a  very  harsh  grating  noise,  or  even  approaches  to  a  musical 
tone.  From  the  slightest  degree  of  roughness  or  prolongation,  to 
the  loudest  possible  bruit,  every  link  is  filled  up  by  murmurs  which 
glide  by  insensible  gradations  into  each  other,  and  unite  the  ex- 
tremes together  under  one  common  denomination.  The  essential 
element  in  their  production  is  an  altered  relation  of  the  blood  to  the 
solid  structures,  whether  by  change  in  the  one  or  in  the  other; 
and  they  are  only  heard  when  the  blood  is  in  motion.  They  there- 
fore correspond  exactly  to  the  systole  or  diastole  of  the  ventricle  as 
the  blood  is  passing  out  of,  or  into  those  cavities:  they  may  com- 
mence a  little  before,  or  a  little  after  the  true  time  of  the  natural 
sound ;  they  may  be  carried  on  through  the  interval  of  pause,  but 
they  cease  directly  when  the  opposite  action  comes  into  play,  either 
to  be  followed  by  the  natural  sound  to  which  that  gives  rise  in  health 
or  by  a  bruit  corresponding  in  time  to  it. 

Their  character,  as  caught  by  the  ear,  is  always  more  or  less  blow- 
ing, the  passage  of  fluid  in  this  respect  offering  very  close  analogies 
to  that  of  air  through  a  constricted  aperture.  We  are  not  sufficiently 
familiar  with  the  laws  of  its  production  to  be  able  to  deduce  from 
an  analysis  of  the  character  of  the  sound  the  exact  changes  in  which 
it  originates,  but  in  general  terms  it  may  be  assumed  that  when  the 
murmur  is  very  soft  the  solid  parts  are  not  very  greatly  altered,  and 
that  when  very  rough,  grating,  or  musical,  there  is  either  very  con- 
siderable constriction,  or  a  semi-detached  mass  floating  down  the  cur- 
rent thrown  into  vibration  as  the  blood  passes.  It  is  a  point  of  some 
difficulty  to  determine  when  roughness  and  prolongation  ought  to 
be  set  down  as  only  a  modification  of  normal  sound — when  they 
ought  to  be  regarded  as  something  additional  or  superadded  taking 
its  place;  the  booming  first  sound  of  hypertrophy,  and  the  redupli- 
cated second  sound  of  unequal  contraction,  ought  never  to  be  called 
bruit. 

The  readiest  mode  of  determining  whether  the  murmur  be  systolic 
or  diastolic  is  to  place  the  finger  where  the  heart  can  be  felt  striking 
on  the  chest.  If  the  sound  commence  at  a  period  equally  distant 
from  each  of  two  impulses,  and  intermediate  between  them,  the  sound 
is  diastolic,  it  ends  just  before  the  heart  strikes  on  the  chest.  If, 
on  the  contrary,  it  be  nearly  coincident  with  the  stroke,  it  is  systolic 
— it  commences  about  the  same  time  as  the  impulse,  and  ends  long 
before  the  next  stroke  is  felt.  When  the  murmur  is  systolic,  the 
sound  produced  by  the  moving  of  the  blood  may  be  either  due  to 
alterations  in  the  orifices  through  which  it  passes,  or  to  changes  in 
the  character  of  the  blood  itself,  or  to  a  combination  of  both.  But 
if  a  bruit  be  recognised  to  be  diastolic,  it  may  be  decided  at  once 
that  there  is  valvular  imperfection ;  and  in  the  majority  of  instances 
there  is  disease  of  the  aortic  valves,  by  which  blood  is  allowed  to 
return  into  the  left  ventricle. 


DIASTOLIC   MURMURS.  275 

If  we  inquire  into  the  mechanism  of  the  circulation,  we  find  that  the  force  with 
■which  the  blood  passes  from  the  auricle  into  the  ventricle  is  much  feebler  than  that 
by  which  it  is  propelled  into  the  arteries,  and  also  that  the  power  of  the  left  ven- 
tricle is  very  much  greater  than  that  of  the  right;  and  inasmuch  as  the  circulation 
through  the  arteries  is  carried  on  during  the  interval  between  one  systole  and  the 
next  by  the  resiliency  or  contractile  force  of  the  vessels,  the  rebound  in  the  aorta 
and  in  the  pulmonic  artery,  in  cases  of  imperfect  valves,  are  each  in  proportion  to 
the  muscular  power  of  their  respective  ventricles.  In  addition  to  this,  we  have 
the  pathological  fact  that  disease  of  the  aortic  valves  is  a  common  occurrence, 
while  disease  of  the  pulmonic  valves  is  very  rare.  During  the  systole  the  ventri- 
cles empty  themselves  of  blood  with  a  force  equal  to  the  contractile  power  of  each 
muscular  wall;  and  the  vibration  of  the  particles  of  blood  thus  produced,  when  its 
relative  proportions  deviate  from  those  of  health,  become  audible,  even  when  there 
is  no  unusual  obstruction  to  the  current.  During  the  diastole,  again,  the  ventri- 
cles are  filled;  and  when  there  is  no  alteration  of  texture  in  the  cardiac  apertures, 
no  change  of  quality  in  the  blood  is  ever  sufficient  to  develop  audible  vibrations 
since  the  movement  is  caused  only  by  the  feeble  contraction  of  the  auricles.  When 
the  auriculo-ventricular  aperture  is  very  much  altered  by  disease,  especially  if  the 
vibratory  power  of  the  blood  be  at  the  same  time  increased  by  anaemia,  a  diastolic 
bruit  is  sometimes  produced  on  the  left  side  of  the  heart;  on  the  right  side  it  has 
never  been  recognised.  When,  again,  the  aortic  valves  close  imperfectly  during 
the  diastole,  the  ventricle  is  partly  filled  from  this  source  also;  and  the  force  with 
which  the  resiliency  of  the  artery  drives  it  back  against  the  roughened  or  imper- 
fect valves,  and  still  more  the  circumstance  of  its  meeting  with  the  current  from 
the  mitral  valve  in  an  opposite  direction,  is  quite  sufficient  to  produce  audible  vi- 
bration. The  very  same  circumstance  might  happen  on  the  right  side  of  the  heart, 
but  I  am  not  aware  that  it  has  ever  been  recorded;  and  the  smaller  amount  of  con- 
tractile force  in  the  pulmonary  artery,  as  well  as  the  rarity  of  disease  of  the  pul- 
monic valves,  would  lead  us  to  suspect  that  the  event  should  be  a  very  rare  one. 

A.  Diastolic  3furmurs. — When  a  diastolic  murmur  is  recognised, 
we  have  really  in  practice  only  to  determine  whether  it  be  aortic  or 
mitral. 

a.  The  probabilities  are  much  in  favour  of  the  former,  consider- 
ing the  relative  frequency  of  each. 

b.  Mitral  diastolic  murmur,  as  it  presupposes  very  considerable 
change  in  texture  in  the  valve,  cannot,  one  would  imagine,  exist  with- 
out a  mitral  murmur  also  accompanying  the  systole :  this  is  not  ne- 
cessarily the  case  in  patency  of  the  aortic  valves. 

c.  The  position  at  which  each  is  heard  in  its  greatest  intensity, 
and  the  direction  in  which  it  is  prolonged,  are  distinct  though  not 
differing  so  greatly  as  to  form  such  a  ready  means  of  diagnosis  as 
might  be  a  priori  expected. 

d.  Further  evidence  of  insufficiency  of  the  aortic  valves,  if  this  be 
presumed  to  be  the  cause  of  murmur,  is  to  be  obtained  from  the 
character  of  the  pulse  which  seems  to  be  left  almost  empty  by  the 
blood  falling  back  upon  the  heart  after  each  stroke,  and  fills  a^ain 
with  a  jerk. 

The  one  of  these  is,  in  fact,  a  murmur  of  regurgitation,  while  the  other  is  not- 
and  this  would  of  itself,  apart  from  the  consideration  of  force,  explain  the  differ- 
ent frequency  of  each :  for  it  is  not  necessary  that  there  be  any  roughness  or  con- 
striction of  the  aortic  valves :  a  smooth  aperture  left  by  tearing  or  ulceration  of  a 
valve  which  permits  regurgitation,  when  the  recoil  of  the  blood  follows  the  systole 
of  necessity  causes  a  diastolic  murmur.  Hence  a  systolic  bruit  at  the  aortic  valves 
is  not  always  to  be  heard  when  a  diastolic  one  is  present,  as  I  believe  is  unavoid- 


276  EXAMINATION  OF  THE  HEART. 

able  at  the  mitral  orifice.     With  this,  too,  is  closely  connected  the  fact  that  the 
'.on  at  which  the  Bound  is  heard  in  i;  t  intensity  is  not  so  different  as 

it  be  supposed.      In  BOmi  .  no  doubt,  the  blond  is  Bet  into  vibration  as  it 

hened  or  constricted  valves  in  its  backward  course;  but  in  other 
vibration  only  begins  when  it  meets  the  opposing  current  from  the 
auricle:  in  the  one  case  it  can  be  traced  for  several  inches  in  a  slanting  direction, 
from  the  root  of  the  aorta  towards  the  apex,  of  pretty  nearly  equal  intensity 
throughout;  in  the  other,  while  the  direction  remains  the  same,  the  length  may  be 
tished  to  about  an  inch  near  the  centre  of  the  heart.     The  mitral  diastolic 
murmur  reaches  to  about  the  same  point,  and  it  will  be  readily  understood  how 
cult  it  must  be  to  determine  a  difference  in  direction,  although  nearly  at  right 
anghs  io  each  other,  when  the  whole  extent  in  each  case  does  notexceed.an  inch. 
There  is,  however,  one  point  characteristic  of  the  mitral  diastolic  murmur:  the  vi- 
bration is  produced  a1  the  valve  itself,  and  the  sound  is  always  heard  in  greatest 
..sitv  there,  and  diminishes  in  distinctness  as  it  passes  across  towards  the 
sternum  to  meet  the  line  of  the  aortic  diastolic  murmur:  such  a  circumstance, 
without  the  hammering  pulse,  would  be  to  my  mind  sufficient  for  the  diagnosis. 
On  the  other  hand,  a  hammering  pulse  would  very  probably  decide  in  favour  of 
insufficiency  of  the  aortic  valves,  even  when  the  loudest  sound  seemed  to  be 
nearest  to  the  apex. 

e.  Systolic  Murmurs. — The  first  question  for  consideration  with 
regard  to  a  murmur  of  this  class  is  ■whether  it  be  formed  at  the  apex 
or  at  the  base  of  the  heart;  and  this  is  to  be  determined  by  the 
relation  of  its  point  of  greatest  intensity  to  the  outline  of  the  organ 
given  by  percussion,  and  the  position  of  the  apex-beat. 

1.  Systolie  Murmurs  at  the  Apex. — Commencing  at  the  centre 
of  the  heart,  we  listen  to  the  quality  and  rhythm  of  the  sounds 
heard  there,  and  move  the  stethoscope  gradually  downwards  and 
outwards:  the  1st  sound  will  have  lost  its  distinctness,  and  will 
present  a  character  of  roughness  at  the  centre,  which  becomes  a 
decided  bruit  at  the  apex. 

a.  When  the  bruit  is  dependent  on  imperfect  closure  of  a  valve, 
the  ear  generally  detects  a  spot  of  limited  dimensions  at  which  the 
murmur  is  much  more  distinct  than  elsewhere — the  roughness  of 
the  1st  sound  passes  suddenly  into  loud  bruit. 

b.  This  point  of  greatest  intensity  varies  somewhat  from  unknown 
causes.  In  insufficiency  of  the  mitral  valve,  it  is  to  be  found  most 
commonly  on  a  level  with  the  apex,  about  an  inch  nearer  to  the 
sternum;  and  next  in  frequency,  about  an  inch  above  the  apex- 
beat,  near  to  the  nipple ;  less  commonly  somewhere  between  those 
points. 

c.  When  the  murmur  is  heard  in  greatest  intensity  considerably 
to  the  right  of  the  apex-beat,  or  at  the  end  of  the  ensiform  cartilage, 
we  may  suspect  that  it  is  due  to  imperfection  of  the  tricuspid  valve; 
but  this  sound  is  less  local,  and  therefore  less  certain. 

d.  If  the  murmur,  though  decidedly  more  distinct  towards  the 
apex  than  at  the  centre  of  the  heart,  present  no  local  point  of 
greatest  intensity,  we  may  still  conclude  that  it  is  a  valvular  sound 
if  the  heart  be  increased  in  size,  and,  in  all  probability,  a  mitral 
murmur. 


SYSTOLIC    MURMURS.  277 

e.  Occasionally,  mere  changes  in  the  quality  of  the  blood  produce 
a  murmur  which  is  audible  over  the  centre  of  the  heart,  and  becomes 
more  distinct  towards  the  apex.  It  is  therefore  necessary,  in  such 
cases,  to  study  the  history  and  symptoms  with  care,  in  order  that 
our  diagnosis  may  not  be  at  variance  with  some  particular  indica- 
tion which  has  been  overlooked. 

2.  Systolic  Murmurs  at  the  Base. — Proceeding  in  the  same 
manner  from  the  centre  of  the  heart,  the  murmur  becomes  louder 
and  more  distinct  as  we  travel  upwards ;  but  the  ear  seldom  comes 
upon  a  point  where  its  intensity  is  so  suddenly  increased  as  at  the 
apex.  Here  it  is  that  bruits  dependent  solely  on  blood-changes  are 
most  commonly  found ;  and  it  is  sometimes  a  matter  of  great  diffi- 
culty to  determine  whether  there  be  any  structural  alteration  or  not. 

a.  When  a  diastolic  bruit  is  also  heard,  there  is  necessarily  val- 
vular disease,  and,  as  we  have  already  mentioned,  probably  disease 
of  the  aortic  valves. 

b.  If  there  be  evidence  of  enlargement  of  the  heart,  the  bruit  is 
also  almost  certainly  dependent  on  disease  of  the  aortic  valves,  or 
root  of  the  aorta.  It  must  be  clearly  made  out  that  the  increased 
action  of  the  organ  is  not  merely  produced  by  nervous  excitement. 

c.  A  murmur  which  can  be  distinctly  localized  at  the  base  of  the 
heart,  and  is  only  faintly  audible,  or  cannot  be  heard  at  all  above 
the  3rd  rib,  is  probably  due  to  disease  of  the  valves ;  one  which  is 
diffuse  and  cannot  be  readily  localized  within  the  limits  of  the 
prsecordial  dulness,  is  more  likely  to  be  caused  by  altered  blood. 

d.  A  murmur  which  can  be  traced  from  below  the  3rd  cartilage 
on  the  left  side  to  the  2nd  interspace  on  the  right,  is  generated  in 
the  aorta;  one  heard  most  distinctly  in  the  2nd  interspace  on  the 
left  side,  is  probably  produced  in  the  pulmonary  artery.  In  the 
one  case  there  may  be  disease  of  the  valve,  in  the  other  there  is 
probably  only  change  in  the  character  of  the  blood. 

e.  When  there  is  any  suspicion  of  disease,  the  history  and  general 
symptoms  must  be  carefully  inquired  into:  an  anaemic  state  may 
account  for  the  existence  of  a  murmur,  and,  under  all  circumstances, 
necessarily  increases  its  intensity. 

Some  authors  distinguish  pre-systolic  and  post-systolic  murmurs  from  such  as 
may  more  properly  be  called  systolic.  The  names  are  ill  chosen,  and  apt  to  con- 
vey a  wrong  impression,  and  the  division  is  too  minute  to  be  followed  by  the  stu- 
dent; but  the  possibility  of  some  variation  in  the  time  of  their  commencement 
should  be  remembered,  so  as  not  to  confound  a  systolic  murmur,  which  does  not 
exactly  coincide  with  the  apex-beat,  with  a  diastolic  one.  The  one  ends  at  or 
near  to  the  time  of  the  beat,  the  other  begins  then,  and  ends  long  before  the  heart 
can  be  again  felt  impinging  on  the  ribs. 

As  a  general  rule,  blood-sounds  are  characterized  by  great  softness;  and  a  whiz- 
zing, grating,  or  musical  noise  may  be  safely  concluded  to  depend  on  some  val- 
vular defect. 

Local  distinctness  is  one  of  the  best  distinguishing  features  of  mitral  insuffi- 
ciency. It  is  to  be  traced  when  no  hypertrophy  of  the  organ  is  present,  and  very 
commonly  coincides  with  a  history  of  rheumatic  fever.  Irregular  action,  feeble- 
ness of  pulse,  congestion  of  the  lungs,  &c,  leave  no  doubt  as  to  the  regurgitation 


278  EXAMINATION    OF    THE    HEART. 

of  the  blood  through  the  mitral  orifice  -when  the  position  of  the  murmur  is  doubt- 
ful, and  may  even  be  sufficient  to  prove  this  condition  when  no  murmur  can  be 
I  1  at  all.  It  is  not  necessary  to  go  into  the  further  question  whether  the  im- 
losure  of  the  valve  depend  upon  alteration  in  its  own  texture  preventing 
the  edges  from  accurately  adapting  themselves  to  each  other,  or  upon  changes  in 
relation  between  the  size  of  the  cavity  aud  aperture,  and  of  the  membranous  valve, 
or  of  the  length  of  the  chordiu  tendiucaa;  though  each  of  these  causes  may  give  rise 
to  mitral  insufficiency. 

An  anaemic  murmur  is  very  seldom  to  be  traced  in  greater  intensity  towards  the* 
apex,  but  that  it  is  so  occasionally  is  quite  certain;  and  the  fact  must  not  be  for- 
gotten. The  general  indications  which  would  confirm  the  opinion  that  it  was  due 
to  blood-change  only,  are  that  the  patient  is  young,  and  has  never  had  rheumatic 
fever,  and  that  the  aspect  is  decidedly  anaemic, — blood  passing  backwards  through 
the  mitral  valve  tends  to  produce  blueness  of  skin,  from  obstruction  to  the  circu- 
lation in  the  lungs:  a  bruit  in  the  carotid  artery  or  in  the  jugular  vein,  when  none 
can  be  traced  at  the  base  of  the  heart,  is  also  a  valuable  indication:  the  pulse  in 
such  circumstances  is  not  at  all  deficient  in  power,  but  it  may  not  be  perceptibly 
so,  even  with  decided  mitral  insufficiency,  when  regurgitation  takes  place  only  to 
a  small  extent.  It  may  be  suggested,  in  explanation  of  this  form  of  blood-murmur, 
that  the  vibration  is  excited  by  the  friction  of  the  particles  against  the  eolumnee 
carnese  when  the  blood  is  in  such  a  condition  that  it  can  be  readily  produced,  aud 
that  it  is  heard  with  greater  iutensity  towards  the  apex  [only  because  the  base  of 
the  heart  and  the  great  vessels  are  deeply  covered  by  lung-tissue,  while  the  apex 
is  comparatively  exposed  in  the  particular  instances  in  which  it  has  been  noticed; 
and  this  is  the  more  probable,  because  it  very  generally  varies  in  position  and  in- 
tensity from  day  to  day. 

Tricuspid  regurgitation  seems  to  be  a  very  common  condition,  and  is  very  rarely 

indicated  by  the  presence  of  a  bruit.     This  is  to  be  explained,  no  doubt,  by  the 

minor  force  of  the  right  ventricle;  aud  it  is  therefore  only  in  conditions  of  very 

decided  disease  that  a  tricuspid  systolic  murmur  is  met  with:  such  cases,  patholo- 

-  know  to  be  very  much  rarer  than  corresponding  disease  of  the  mitral  valve. 

At  the  base  of  the  heart  bruits  are  so  often  dependent  on  blood-changes,  that 
the  diagnosis  can  rarely  be  made  with  any  approach  to  certainty  from  the  charac- 
ter and  position  of  the  murmur  itself;  and  we  therefore  look  in  the  first  instance 
to  the  aspect  of  the  patient,  the  history  of  the  case,  and  the  evidence  of  disease  of 
the  heart  from  diastolic  murmur  or  hypertrophy,  to  aid  in  the  determination.  In 
no  case  perhaps  is  error  more  liable  to  be  committed  than  in  mistaking  nervous 
excitement  for  hypertrophy,  and  deciding  that  therefore  the  bruit  heard  is  an  in- 
dication of  valvular  disease. 

In  speaking  of  chronic  blood-ailments  (Chap.  YIIL,  \  4)  those  circumstances 
were  mentioned  in  detail  in  which  an  ana?mic  bruit  is  probably  to  be  heard;  and 
it  was  there  stated  that,  as  the  cause  of  the  production  of  sound  is  in  the  blood 
itself,  the  motion  among  its  particles  caused  by  its  passage  through  the  healthy 
heart  is  sufficient  to  excite  the  vibration,  and  that  the  point  at  which  the  bruit  is 
heard  in  its  greatest  intensity  is  only  that  which  is  most  superficial;  but  that,  as  a 
general  rule,  it  tends  to  be  diffuse,  and  is  audible  over  a  large  surface.  In  the 
majority  of  cases,  systolic  murmur  at  the  base  heard  relatively  louder  over  the  2d 
interspace  on  the  right  side  of  the  sternum,  indicates  disease  of  the  aortic  valves, 
while  one  relatively  louder  in  the  same  interspace  on  the  left  side,  directly  over 
the  base  of  the  heart,  or,  extending  towards  the  left  shoulder,  is  only  a  blood- 
eound:  a  local  bruit  in  the  3d  interspace  on  the  left  side,  which  is  not  propagated 
in  cither  direction,  is  most  commonly  caused  by  valvular  disease. 

As  the  rationale  of  these  rules,  the  following  considerations  may  be  suggested. 
Bruits  are  all  heard  more  loudly  over  an  interspace  than  over  the  rib  immediately 
above  or  below ;  the  3d  interspace  on  the  left  side  is  that  in  which  the  sound  ac- 
tually produced  at  the  valve  is  best  heard;  and  for  all  practical  purposes  we  may 
for  the  present  disregard  disease  of  the  pulmonic  valves  altogether,  and  assume 
that  the  question  lies  between  disease  of  the  aortic  valves  and  ana?mia.  True  val- 
vular sound  is  therefore  necessarily  heard  best,  unless  the  heart  be  much  enlarged 
upwards,  in  the  3d  interspace;  and  it  may  possibly  not  be  propagated  to  any  dis- 
tance beyond,  but  heard  there  only:  if,  on  the  other  hand,  any  anosmia  be  present 


BLOOD   MURMURS.  279 

as  well  as  disease  of  the  valve,  the  sound  will  be  propagated  along  the  aorta,  not 
along  the  pulmonary  artery;  and  therefore  it  will  be  relatively  loudest  on  the  right 
side  above  the  3d  rib,  though  not  so  loud  there  as  where  it  is  actually  produced. 
The  case  of  a  simple  anaemic  bruit  is- quite  different:  there  is  no  distinct  point  in 
the  course  of  its  passage  through  the  heart  where  the  blood  is  thrown  into  vibra- 
tion, but  wherever  vibration  occurs,  the  sound  is  produced:  practically  the  pul- 
monary artery  is  most  superficial,  and  therefore,  though  it  can  be  heard  in  the 
.  aorta,  the  bruit  is  relatively  louder  iu  the  pulmonary  artery,  and  consequently  at 
that  interspace  where  in  very  thin  persons  this  artery  may  be  often  felt  pulsating; 
the  2d  on  the  left  side. 

In  consequence  of  the  statement  here  made,  it  will  be  seen  that  proof  of  the  nc- 
tual  existence  of  ansemia,  whiffing  sounds  in  the  arteries,  "bruit  de  diable"  in  the 
jugular  veins,  &c,  although  it  throw  some  doubt  over  the  probability  of  true  val- 
vular murmur,  must  not  be  assumed  to  disprove  it  altogether.  It  is  probable  that 
when  a  valvular  bruit  is  distinctly  propagated  along  the  artery,  there  is  almost 
always  some  degree  of  anamia  to  account  for  it;  and  that  the  really  valuable  in- 
dication is  that  there  is  a  point  at  which  the  vibration  commences,  while  its  pro- 
pagation along  one  vessel  or  the  other  is  of  minor  importance;  because,  although 
it  be  true  that  a  pulmonic  valve  murmur  is  exceedingly  rare,  the  principles  of  dia- 
gnosis must  recognise  its  possibility,  and  endeavour  to  prove  its  presence  or  ab- 
sence. Such  a  murmur  is  very  likely  to  be  propagated  along  the  pulmonary  ar- 
tery ;  and  here,  again,  the  only  valuable  indication  would  be  the  existence  of  a 
point  somewhere  below  the  3d  rib,  probably  very  close  to  or  under  the  sternum, 
from  whence  the  vibration  commences.  If  any  one  will  take  the  trouble  to  listen 
to  the  sound  heard  in  the  carotid  arteries  in  a  few  instances  of  acknowledged  dis- 
ease of  the  aortic  valves,  he  will  very  quickly  find  that  the  propagation  of  the  bruit 
depends  on  something  else  than  the  diseased  valve  which  produces  it:  the  subject 
has  been  mentioned  at  some  length,  because  the  direction  which  the  sound  takes 
is  often  alluded  to  as  the  great  indication  in  diagnosis. 

This  inquiry  into  the  means  of  distinguishing  between  a  blood- 
sound  and  a  valvular  murmur  is  necessarily  somewhat  complicated; 
and  yet  it  may  become  of  very  considerable  importance  when,  for 
example,  in  watching  a  case  of  acute  rheumatism,  we  have  to  deter- 
mine whether  a  bruit  of  some  sort  indicate  the  supervention  of 
endocarditis.  The  rules  which  may  be  laid  down  as  the  most 
valuable  for  the  guidance  of  the  student  in  such  a  case  are  the 
following : — 1.  To  observe  the  point  of  its  greatest  intensity  with 
reference  to  the  three  principal  positions  referred  to,  (a)  the  apex, 
(b)  the  base  at  the  3rd  left  interspace,  (c)  above  the  base  at  the  2nd 
left  interspace.  2.  To  ascertain  in  how  far  at  the  points  (a)  and 
(5)  it  is  capable  of  distinct  localization.  3.  If  its  character  be,  on 
the  contrary,  at  all  diffuse,  to  observe  whether  it  can  be  traced 
towards  or  across  the  sternum  or  towards  the  shoulder.  4.  To 
watch,  from  day  to  day,  whether  there  be  any  variation  in  intensity 
at  different  points. 

In  addition  to  these  considerations,  account  must  be  taken  of  the 
past  history  of  the  case,  as  it  may  show  the  possibility  of  previous 
disease;  and  of  the  present  condition  of  the  circulation,  as  it  may 
indicate  such  an  amount  of  excitement  as  must  of  necessity  exist 
when  endocardial  inflammation  is  going  on,  or  such  a  state  of  quies- 
cence as  is  incompatible  with  it.  Nor  is  it  to  be  forgotten  that 
bruit  is  produced  in  many  cases  of  thoracic  aneurism,  and  that  these 
have  to  be  separated  by  their  position  before  the  sound  is  taken  as 
an  indication  of  disease  of  the  valves. 


280 


CHAPTER  XXII. 

DISEASES    OP   THE   HEART. 

History  and  Symptoms — Acute  and  Chronic  Disease — their  Com- 
mencement often  Obscure. — §  1,  Pericarditis — its  Signs  and 
Symptoms — §  2,  Endocarditis  —  its  Signs  and  Symptoms  — 
Sources  of  Fallacy — the  Origin  of  Cardiac  Inflammation  in 
Rheumatic  Fever — §  3,  Hypertrophy — its  Indications — its  Causes 
— §  4,  Dilatation — the  Flabby  or  Fatty  Heart — Association  with 
Hypertrophy — §  5,  Valvular  Lesion — with  and  ivithout  Bruit — 
Mechanism  of  the  Circulation — Production  of  Murmurs — other 
Indications — Obscure  Cases — Causes  of  Disease  of  the  Heart — 
Associations. 

The  history  of  tlie  various  conditions  of  disease  of  the  heart 
must  of  necessity  present  extreme  contrasts,  as  they  are  calculated 
to  interfere  very  greatly  or  not  at  all  with  the  general  comfort  and 
well-being  of  the  patient.  Commencing  as  some  do  in  the  most 
gradual  and  imperceptible  manner,  a  long  period  elapses  in  their 
history  during  which  they  are  utterly  unsuspected  by  the  patient, 
and  may  only  be  casually  discovered  by  the  physician:  by-and-by 
they  begin  to  interfere  with  the  circulation,  and  consequently  with 
the  breathing,  and  the  patient  becomes  short-winded,  or,  as  he 
supposes,  asthmatic;  and  then  an  educated  practitioner  readily 
traces  the  true  cause  of  the  symptoms.  In  another  set  of  cases  a 
sudden  strain  is  put  upon  the  diseased  organ,  which  overpowers  its 
imperfect  action,  hitherto  unrecognised,  and  irregular  contraction, 
laboured  movement,  and  impeded  circulation  at  once  develop 
themselves,  and  are  assumed  to  be  the  commencement  of  disease  in 
the  narrative  of  the  patient.  Not  unlike  these  last  are  a  few  rare 
cases,  in  which  the  strain  has  been  so  great  as  to  rupture  some  part 
of  the  delicate  mechanism  in  states  of  perfect  health,  and  to  have 
been  in  reality  the  beginning  of  the  disease.  In  yet  another  class 
we  are  able  to  trace  the  history  of  inflammatory  action  by  pain  and 
dyspnoea  in  recent  cases,  or  by  the  account  of  circumstances  likely 
to  have  excited  it,  in  those  of  long  standing,  and  by  the  continuance 
of  disordered  function  since  the  primary  ailment. 

"We  thus  divide  the  cases  naturally  into  the  acute  and  chronic 
diseases  of  the  heart;  the  one  forming  only  a  very  small  section, 
exceedingly  limited  as  to  the  causes  of  their  existence;  the  other 
embracing  by  far  the  larger  number  of  cases,  which  can  be  traced 
back  either  to  partial  recovery  from  an  acute  attack,  or  to  a  variety 
of  other  causes,  some  of  which  are  very  vague  and  ill-defined. 

Among  the  acute  cases  we  find  pain  or  dyspnoea  not  unfrequently 


DISEASES    OF   THE    HEART.  281 

present;  among  the  chronic  they  are  unusual,  at  least  as  a  perma- 
nent condition,  and  'when  met  with,  sometimes  assume  the  charac- 
ters which  have  been  ascribed  to  angina  pectoris.  (Chap.  XVI. 
§  4.)  The  dyspnoea  of  inflammation  may  be  spoken  of  rather  as  a 
catching  in  the  breathing,  or  feeling  of  anxiety  connected  with  it; 
that  of  chronic  disease  is  more  decidedly  what  patients  call  "short- 
ness of  breath,"  felt  in  running,  in  going  up-stairs,  &c.  The  cha- 
racter of  the  pulse  of  course  very  often  offers  direct  evidence  of 
disease  of  the  heart:  and,  in  addition  to  this,  the  presence  or  his- 
tory of  rheumatic  fever,  of  inflammation  of  the  pleura,  of  disease 
of  the  kidney  and  of  dropsy,  as  the  more  constant  associations  of 
acute  or  chronic  disease  of  the  heart,  are  each  to  be  viewed  in  the 
light  of  symptoms,  or  at  least  indications  of  its  presence.  Among 
them  all,  that  which  leads  most  frequently  to  the  detection  of  cardiac 
inflammation  is  the  presence  of  acute  rheumatism. 

§  1.  Pericarditis. — If  any  of  .the  signs  of  those  diseases  just 
mentioned  as  being  associated  with  cardiac  inflammation  be  pre- 
sented to  our  observation,  and  if  on  examination  of  the  heart,  peri- 
cardial friction  be  made  out,  there  can  be  no  doubt  that  pericardi- 
tis exists:  other  indications  of  inflammatory  action  will  not  be 
wanting,  but  here  there  is  less  need  for  the  evidence  of  correlative 
symptoms  than  in  other  cases.  When  friction- sound  is  absent,  it 
may  be  annulled  either  by  the  presence  of  fluid,  or  by  universal 
adhesion :  in  either  case,  the  general  symptoms  must  be  decided  be- 
fore we  can  be  warranted  in  pronouncing  such  a  diagnosis,  and 
along  with  these,  not  in  opposition  to  them,  we  shall  find  in  the 
former  very  extended  dulness,  especially  in  an  upward  direction, 
and,  as  usually  described,  assuming  somewhat  of  a  pear-shaped 
form;  undulatory  movement  may  sometimes  be  visible  over  the 
precordial  space,  while  the  heart's  action  is  excited,  laboured,  or 
irregular,  and  the  apex-beat  somewhat  elevated;  the  ordinary 
sounds  of  the  heart  are  distant  and  indistinct  over  the  position  of 
percussion  dulness,  becoming  louder  and  more  natural  above  the 
space  occupied  by  the  fluid ;  tenderness  over  the  precordial  space, 
pain,  and  dyspnoea,  and  great  distress  from  any  sudden  movement, 
are  also  met  with  in  such  cases.  On  the  other  hand,  when  the  sur- 
faces are  agglutinated  together,  the  evidence  is  more  obscure ;  per- 
haps the  most  important  points,  when  taken  in  connexion  with  the 
general  symptoms,  are  persistently  perverted  rhythm  with  nothing 
else  to  account  for  it,  and  a  certain  degree  of  obscurity  of  sounds, 
accompanied  by  increased  and  excited  action.  Taken  along  with 
the  presence  of  precordial  pain,  distress  or  anxiety,  and  dyspnoea, 
the  diagnosis  may  be  pretty  certain  in  a  case  of  acute  rheumatism 
or  severe  pleurisy,  where  pericarditis  is  to  be  looked  for,  but  can 
never  be  relied  on  when  there  is  nothing  else  to  guide  us  to  it. 

In  the  early  stage,  excited  action,  altered  rhythm,  and  creaking 
noise  before  friction  is  established,  should  prepare  us  for  its  appear- 


DISEASES    OF    THE    HEART. 

ance,  especially  if  pain  occur  in  the  course  of  rheumatism,  pleurisy, 
or  albuminuria.  In  the  latter  disease,  the  plastic  exudation  i3 
generally  much  less,  the  tendency  to  pour  out  fluid  much  greater. 

In  the  course  of  pericarditis  we  must  be  prepared  for  the  occur- 
rence of  pleurisy,  and  in  inflammation  of  the  pleura  for  its  attack- 
ing the  pericardium.  When  the  friction  occurs  in  the  immediate 
vicinity  of  the  heart,  it  may  be  difficult  to  say  by  which  membrane 
the  sound  is  produced ;  because  even  when  the  breath  is  held,  the 
impulse  of  the  heart  may  cause  pleuritic  friction.  Generally  the 
diagnosis  is  not  difficult,  and,  besides,  it  is  not  of  very  great  im- 
portance. 

The  Btndent  must  refer  to  the  last  chapter  for  the  distinguishing  characters  of 
friction.  His  attention  must,  however,  be  specially  called  to  two  points  in  regard, 
to  the  diagnosis  of  pericarditis,  a.  All  double  bruits  are  not  friction,  b.  Friction 
may  exist  as  a  single  sound.  Independently  of  such  considerations  as  its  loud- 
ness, distinctness,  rubbing  character,  superficial  position,  &c,  which  can  only  be 
learnt  by  the  habit  of  constant  observation,  and  are  never  thoroughly  trust- 
worthy, the  best  and  safest  indication  is  to  be  obtained  from  comparing  the  rhythm 
of  the  sounds  heard  over  the  arch  of  the  aorta,  beyond  the  pericardial  sac,  with 
that  of  the  bruit  wherever  heard  most  distinctly.  An  endocardial  murmur  when 
double,  corresponds  in  time  to  the  first  and  second  sounds  'heard  over  the  arch, 
while  friction  does  not:  a  single  murmur,  when  anomalous  in  time,  is  most  likely 
to  be  pericardial;  if  endocardial,  it  would  correspond  either  to  the  systole  or  the 
diastole. 

§  2.  Endocarditis. — The  presence  of  an  endocardial  murmur  is 
not  decisive  of  endocarditis ;  for  it  may  be  of  long  standing,  or  it 
may  be  merely  functional.  Excitement  of  the  heart's  action,  per- 
sistent and  not  arising  from  some  temporary  cause,  as  well  as  fe- 
brile disturbance  and  cardiac  anxiety,  must  be  present  to  render 
the  diagnosis  certain ;  indeed,  in  affection  of  the  mitral  valve,  these 
symptoms  may  for  some  days  precede  the  development  of  the  mur- 
mur. And  in  old  standing  disease,  where  a  murmur  already  exists, 
their  occurrence  may  lead  to  a  well-grounded  suspicion  of  fresh  in- 
flammatory action  and  exudation,  especially  during  the  existence  of 
rheumatism.  Of  murmurs  developed  under  observation,  the  most 
important  is  that  indicative  of  mitral  disease,  and  next,  that 
already  described  as  found  at  the  base  of  the  heart,  of  local  cha- 
racter, and  inclining  towards  the  right  side  of  the  sternum.  When 
general  symptoms  are  wanting,  and  the  heart  is  quiet,  a  systolic 
murmur  at  the  base,  diffuse  in  character,  or  one  heard  best  above 
the  3rd  rib,  may  be  generally  disregarded ;  in  cases  of  doubt  it  is, 
however,  safer  to  act  on  the  suspicion  of  endocarditis.  Its  incur- 
sion has  been  most  frequently  recognised  while  watching  the  heart 
in  cases  of  rheumatic  fever,  but  its  existence  must  not  be  supposed 
to  be  limited  to  that  disease,  and  in  a  large  number  of  instances  I 
doubt  not  endocarditis  has  been  assumed  when,  in  fact,  the  valvular 
disease  had  been  developed  in  a  previous  attack. 

The  murmur  at  the  base,  at  first  developed  by  the  presence  of  a  few  adhering 
vegetations,  is  of  course  very  local,  and  indeed  amounts  to  little  more  than  a  rough- 
ness of  the  1st  sound  at  the  3rd  interspace.     The  murmur  at  the  apex,  again,  can- 


ENDOCARDITIS.  283 

not  be  produced  until  the  deposit  is  of  considerable  amount;  for,  as  we  have  al- 
ready seen,  the  contraction  of  the  auricle  has  not  sufficient  force  to  develop  a  mur- 
mur during  the  ventricular  diastole,  except  in  rare  instances,  while  a  systolic 
mitral  murmur  necessarily  implies  mitral  insufficiency;  it  is  consequently  pre- 
ceded by  no  changes,  but  appears  suddenly,  as  soon  as  the  lymph  on  the  valves 
prevents  their  perfect  adaptation.  In  neither  case,  therefore,  does  the  stethoscope 
afford  us  very  sure  means  of  diagnosis  in  the  early  stage  of  endocarditis:  the 
modification  of  sound  at  the  base  is  the  earliest  when  the  aortic  valves  suffer;  but 
it  is  in  some  measure  obscure  and  uncertain,  from  the  possibility  of  blood-change 
in  rheumatism,  and  practically  the  aortic  valves  are  not  involved  so  soon  as  the 
mitral.  Hence  it  is  important  to  view  general  symptoms,  and  to  anticipate  the 
appearance  of  the  physical  signs,  which  come  too  late  to  be  of  much  service. 

In  the  progress  of  rheumatic  fever  it'  is  the  duty  of  the  medical 
attendant  to  examine  the  condition  of  the  heart  at  every  visit.  No 
fact  is  better  established  than  the  association  of  cardiac  inflamma- 
tion with  this  disease ;  and  if  remedies  caD  avail,  the  time  for  their 
employment  is  at  the  first  inroad  of  the  inflammatory  action ;  the 
organ  once  spoiled  is  seldom  restored  to  a  perfectly  healthy  state: 
it  is  perhaps  therefore  not  out  of  place  to  say  a  few  words  upon 
the  subject  of  the  precursory  or  premonitory  phenomena,  as  they 
may  be  called.  It  would  appear  that  when  the  perspiration  is  less 
abundant,  and  less  sour-smelling,  when  the  skin  is  dry  and  the 
odour  rancid,  the  liability  to  cardiac  complication  is  greater.  The 
pulse  is  sharper  and  firmer,  the  heart  itself  becomes  excited,  its 
systole  is  sharp  and  shrill,  and  its  impulse  against  the  chest  more 
perceptible,  when  there  is  any  tendency  to  inflammation  of  that 
organ:  but  this  excitement  may  be  calmed,  and  no  further  change 
observed.  Next  we  find  that  there  is  some  alteration  in  rhythm; 
the  1st  sound  seems  to  be  shorter,  and  the  1st  interval  longer  than 
in  health ;  at  least  there  is  a  notable  change  in  the  proportionate 
duration  of  the  1st  and  2nd  sounds  and  the  1st  and  2nd  intervals: 
this,  too,  may  subside,  but  is  very  liable  to  be  followed  by  more  de- 
cided evidence  of  inflammation.  Pain  or  dyspnoea  may  occur  be- 
fore friction  or  bruit  of  any  kind,  but  they  seldom  precede  the 
other  indications,  and  ought  not  to  be  the  first  suggestion  of  cardiac 
complication.  If  after  the  changes  just  spoken  of  a  slight  creaking 
be  heard,  we  may  be  sure  pericardial  friction  is  just  about  to  show 
itself;  if  a  slight  roughness  of  the  1st  sound  at  the  base,  that  endo- 
cardial murmur  will  soon  be  detected. 

^  Not  unfrequently  the  cardiac  affection,  and  the  consequent  changes 
in  the  sounds  of  the  heart,  have  been  developed  before  the  patient 
comes  under  observation ;  and  it  is  important  to  be  able  to  deter- 
mine what  is  the  exact  condition  of  the  organ  at  the  time  of  ex- 
amination. The  following  rules  may  be  laid  down  for  the  guidance 
of  the  student: — 

a.  "When  pericardial  friction  exists,  the  case  is  clearly  one  of 
pericarditis. 

b.  When  an  endocardial  murmur  is  present,  it  is  well  to  inquire 
whether  the  patient  have  ever  previously  suffered  from  rheumatism. 


2S4  DISEASES    OF    THE    HEART. 

or  have  had  any  symptoms  of  disease  of  the  heart  before  his  present 
attack. 

e.  A  systolic  aortic,  or  mitral  murmur,  as  already  described, 
found  in  a  first  attack  of  acute  rheumatism,  with  no  evidence  of 
enlargement  or  irregular  action,  is  very  probably  the  result  of  re- 
cent endocarditis. 

J.  A  murmur  heard  on  the  first  examination  of  the  heart  in  a 
second  or  third  attack  of  acute  rheumatism,  or  along  with  enlarge- 
ment and  irregular  action,  or  when  there  is  a  history  of  previous 
palpitation,  dyspnoea,  or  dropsy,  is  not  to  be  regarded  as  evidence 
of  endocarditis,  which  can  only  be  inferred  from  concomitant 
symptoms. 

e.  When  pain  and  dyspnoea  are  complained  of,  and  yet  no  morbid 
sound  can  be  detected,  the  pericardium  may  be  full  of  fluid.  In 
such  circumstances  it  will  be  observed  that  the  natural  sounds  of 
the  heart  are  obscure  and  distant  in  the  precordial  region,  but  be- 
come clear  and  distinct  above  the  base  of  the  heart;  the  dulness  is 
manifestly  extended,  especially  upwards,  and  its  pyriform  shape  may 
perhaps  be  made  out,  or  undulatory  movement  may  be  seen.  The 
action  of  the  heart  is  excited  and  increased,  or  irregular ;  and  this 
forms  a  striking  contrast  to  the  weakness  of  the  sounds. 

/.  In  rare  cases,  universal  adhesion  of  the  pericardium  may  have 
annulled  the  friction-sound.  This  circumstance  is  to  be  borne  in 
mind  when  the  evidence  of  previous  inflammation  is  distinct  and 
the  sounds  of  the  heart  are  modified  in  a  way  that  we  cannot  other- 
wise account  for,  especially  when  there  is  persistent  alteration  in, 
rhythm.  There  is  probably  no  combination  of  signs  especially  dia- 
gnostic of  the  condition  here  referred  to. 

The  distinction  between  endocarditis  and  old  valvular  murmur  is  very  constantly 
lost  sight  of;  without  any  further  question,  a  bruit  is  at  once  held  to  be  conclusive 
evidence  of  inflammation.  This  is  a  very  grave  error  in  diagnosis,  because,  as  we 
regard  pericarditis  and  endocarditis  as  something  different  from  tbe  blood-change 
of  rheumatic  fever,  and  as  of  much  more  serious  import  to  the  patient's  health 
and  life,  we  are  justified  in  disregarding  the  rheumatism,  and  trying  at  all  hazards 
to  save  the  central  organ  from  damage;  but  such  treatment  is  never  to  be  adopted 
without  reason,  and  is  calculated  to  be  injurious  when  based  on  a  mistaken  view 
of  the  case.  At  the  same  time  it  is  to  be  borne  in  mind  that  a  valve  once  thick- 
ened by  inflammatory  action  shows  a  remarkable  proclivity  to  future  attacks,  and 
at  a  post  mortem  examination  often  exhibits  fringes  of  fresh  lymph,  when  the 
symptoms  during  life  were  scarcely  such  as  would  have  justified,  even  if  they  had 
suggested,  the  diagnosis  of  endocarditis. 

The  harmony  of  general  symptoms  and  physical  signs  has  been  much  insisted 
on  in  the  preceding  pages,  because  the  blood-change  that  occurs  in  association 
with  what  we  call  rheumatic  fever  is  unquestionably  one  that  tends  towards  ane- 
mia, as  is  proved  by  the  development  of  blood-sounds  during  its  continuance,  which 
were  not  heard  previously, — a  circumstance  not  observed  in  true  inflammations,  as 
the  term  is  generally  understood.  To  apply  depletory  nieasures  when  an  anaemic 
murmur  is  heard,  is  surely  what  no  experience  would  justify  or  recommend. 

The  most  trustworthy  indications  of  the  liability  to  inflammation,  or  of  its  actual 
existence,  are  to  be  found  in  altered  rhythm  and  persistent  excitement,  if  by  this 
term  we  understand  something  different  from  increased  action.  It  is  that  which 
is  found  in  its  simplest  form  in  nervous  palpitation ;  and  the  student  should  make 


HYPERTROPHY.  285 

himself  familiar  as  soon  as  possible  with  the  difference,  which  is  by  no  means  dif- 
ficult to  recognise,  between  the  character  of  the  sounds  as  they  are  heard  in  the 
excitement  of  nervous  palpitation,  the  increased  action  of  hypertrophy,  and  the 
quickened  movement  of  fevers  and  inflammations  of  other  organs. 

Not  less  important  are  pain  and  dyspnoea ;  but  they  are  often  absent,  and  may 
be  both  dependent  simply  on  rheumatism  of  the  intercostal  muscles,  or  even  per- 
haps of  the  diaphragm.  Tenderness  between  the  ribs,  pain  aggravated  by  move- 
ment, or  felt  over  an  extensive  surface,  and  the  absence  of  signs  of  cardiac  inflam- 
mation, are  the  evidences  on  which  we  base  our  conclusion  that  intercostal  rheu- 
matism is  the  cause  of  the  difficult  or  painful  respiration.  On  the  other  hand,  we 
must  be  careful  to  observe  that  the  tenderness  is  not  really  in  the  pericardium, 
when  it  is  increased  by  pressure. 

It  may  seem  scarcely  possible  that  enlargement  of  the  heart  should  be  mistaken 
for  pericardial  effusion ;  but  there  is  a  certain  similarity  when  the  cavities  are 
greatly  dilated  without  thickening  of  the  walls.  The  simulation  of  undulatory 
movement  has  been  already  mentioned,  and  the  error  has  been  due  to  this  circum- 
stance, attended  as  it  necessarily  is  with  increased  dulness  on  percussion.  The 
difficulty  can  only  arise  when  along  with  the  dilatation  the  sounds  are  obscured  by 
the  existence  of  valvular  murmur,  and  especially  when  heard  both  at  base  and 
apex:  in  such  a  case,  when  pain  is  complained  of,  or  dyspnoea  has  been  recently 
increased,  and  any  of  those  conditions  are  present  which  may  act  as  causes  of 
pericarditis,  the  doubt  will  occur  to  every  observant  mind.  The  quasi-undulatory 
movement,  however,  will  not  long  deceive  any  one  of  much  experience, — though 
analogous,  it  is  in  reality  different :  but,  in  addition  to  this,  a  very  safe  guide  is  to 
be  found  in  the  circumstance  that  the  presence  of  fluid  diminishes  the  distinctness 
with  which  sounds  are  transmitted  to  the  ear,  and  that  above  the  region  of  the 
dulness  the  sounds  of  the  heart,  whether  marked  by  bruit  or  not,  are  heard  with 
much  greater  distinctness  than  any  where  in  the  pracordial  space ;  and  this  i3 
something  quite  distinct  from  the  difference  between  the  intensity  of  a  bruit  as 
ordinarily  made  out  in  the  one  or  in  the  other  situation.  For  it  is  to  be  remem- 
bered that  we  are  supposing  an  advanced  stage  of  pericarditis,  and  that  if  there  be 
not  much  fluid,  there  must  be  friction  :  if  there  be  much  effusion,  the  bruit  or  the 
natural  sound  are  only  heard  as  distant  and  obscure. 

§  3.  Hypertrophy. — Increased  dulness  on  percussion,  heaving 
impulse,  sounds  muffled  and  indistinct  though  usually  loud,  a  full 
firm  pulse,  and  general  throbbing  of  the  arteries,  indicate  simple 
hypertrophy:  the  heart's  action  is  not  irregular.  Such  a  condition, 
however,  is  one  of  comparative  rarity:  the  increase  of  muscular 
power  only  results  from  the  preservative  action  of  nature,  because 
some  extraordinary  demand  has  been  made  upon  it;  and  the  cause 
usually  resolves  itself  into  some  obstruction  to  the  circulation,  and 
the  evidence  of  this  condition  tends  to  obscure  that  of  the  hyper- 
trophy: the  sounds  may  be  altered  by  the  presence  of  a  bruit,  the 
pulse  maybe  weak  from  mitral  insufficiency,  and  the  action  may  be 
irregular  from  accompanying  dilatation.  It  is  only  when  the  heart 
has  attained  considerable  size  that  this  lesion  becomes  of  much  im- 
portance ;  and  it  is  then  chiefly  to  be  regarded  as  an  index,  more 
or  less  distinct,  of  the  severity  of  those  conditions  with  which  it  is 
associated. 

On  the  left  side  of  the  heart  it  is  much  more  common  than  on  the  right,  and 
this  as  a  necessary  result  of  the  primary  diseases  from  which  it  is  derived.  Its 
simplest  form  is  produced  by  degeneration  of  the  coats  of  the  artery,  and  by 
Bright's  disease  of  the  kidney;  and  it  is  very  constantly  found  after  inflammation 
and  atheromatous  disease  of  the  valves,  or  partial  adhesions  of  the  pericardium : 


280  DISEASES    OF    THE    HEART. 

all  of  those  especially  affect  the  left  side.  On  the  right,  the  chief  cause  of  hyper- 
trophy a  the  impediment  offered  to  the  pulmonary  circulation  by  an 
emphysematous  condition  of  lung. 

§  4.  Dilatation. — Increased  dulness  without  heaving  impulse,  a 
quasi-undulatory  movement,  and  irregular  action;  sharp,  shrill,  or 
feeble,  and  flapping  sounds;  a  soft,  weak  pulse,  with  general  dys- 
pnoea and  depression,  indicate  a  dilated  heart.  Its  signs  and  symp- 
toms are  those  of  enfeebled  power,  and  hence  they  have  close 
analogy  with  those  produced  by  what  used  to  be  called  a  flabby, 
now  very  generally  believed  to  be  a  fatty  heart;  the  increased 
dulness  and  the  undulatory  movement  are,  of  course,  absent  when 
there  is  no  dilatation.  These  are  the  conditions  most  commonly 
associated  with  the  pain  and  distress  of  angina  pectoris,  and  its 
allied  spasms. 

The  diagnosis  of  fatty  heart  derives  much  confirmation  from  observing  a  pre- 
mature development  of  the  arcus  senilis,  because  the  tendency  to  fatty  degenera- 
tion in  one  tissue  is  not  improbably  associated  with  the  same  tendency  in  others  ; 
but  it  is  rather  to  be  inferred  from  the  pathological  fact  that  simple  dilatation  is 
exceedingly  rare,  and  consequently  when  we  cannot  discover  any  cause  for  the 
symptoms  of  enfeebled  power,  we  suspect  fatty  degeneration.  Dilatation  without 
defeneration  belongs  especially  to  aortiG  regurgitation,  mitral  insufficiency,  and 
completely  adherent  pericardium.  The  valvular  lesions  produce  complications 
which  have  yet  to  be  noticed;  the  pericardial  adhesion  tends  to  increase  the  ap- 
pearance of  undulatory  movement.  In  a  large  number  of  cases  more  or  less  hy- 
pertrophy accompanies  the  dilatation,  and  thus  the  physical  signs  become  infi- 
nitely varied.  1  believe  that  irregularity  of  action,  accompanying  evidence  of  en- 
largement, may  be  almost  always  taken  as  an  indication  of  the  presence  of  some 
degree  of  dilatation. 

§  5.  Valvular  Lesion. — This  form  of  disease  is  that  which  is 
essentially  associated  with  endocardial  murmur:  but  as,  in  speaking 
of  the  murmur,  it  has  been  shown  how  it  may  be  produced  without 
alteration  of  the  structure  of  the  valves,  so  here  it  is  to  be  remem- 
bered that  valvular  lesion  may  be  found  after  death,  which  has  not 
been  discovered  by  the  presence  of  a  bruit  during  life.  Our  inquiry 
must,  therefore,  not  be  limited  to  the  use  of  the  stethoscope;  we 
must  ascertain  the  previous  existence  of  rheumatism,  or  the  coinci- 
dence of  ailments  with  which  we  know  that  disease  of  the  heart  is 
more  or  less  constantly  associated:  among  these  one  of  the  most 
frequent  is  dropsy,  and,  as  a  general  rule,  it  may  be  said  that,  when 
not  produced  by  albuminuria,  it  is  seldom  found  with  any  disease  of 
the  heart  of  which  valvular  imperfection  is  not  a  prominent  feature. 
Probably,  in  the  first  instance,  valvular  lesion  always  gives  rise  to 
bruit:  it  is  when  the  circulation  becomes  laborious  and  irregular 
that  the  murmur  is  lost  or  indistinct,  and  then  the  evidence  of  dis- 
ease is  so  clear  that  it  is  quite  unnecessary  as  a  confirmation,  and 
its  value  only  consists  in  its  giving  an  explanation  of  the  circum- 
stances which  have  led  to  the  advanced  changes  of  which  other 
indications  have  rendered  us  cognizant. 

In  diagnosis  we  have,  therefore,  to  do  with  the  fact  of  imperfect 


VALVULAR    LESION.  287 

closure  of  the  valves  under  two  aspects.  In  its  first  appearance, 
prior  to  other  changes,  when  we  may  be  called  upon  to  determine 
how  it  is  likely  to  affect  the  duration  of  life  or  the  enjoyment  of 
health,  when  the  presence  of  the  bruit  is  the  only  evidence  of  dis- 
ease ;  and,  at  a  later  period,  when  very  considerable  alteration  of 
muscular  structure  has  taken  place,  and  the  imperfection  of  the 
valve,  though  in  truth  the  cause  of  these  changes,  may  or  may  not 
be  revealed  by  any  actual  murmur:  in  the  latter,  as  in  the  former, 
there  are  many  important  questions  with  reference  to  the  prognosis 
and  treatment,  with  which  diagnosis  has  not  any  thing  further  to  do 
than  in  establishing  the  fact. 

With  reference  to  the  first  class  of  cases,  the  student  has  to  re- 
member the  three  forms  of  endocardial  murmur  which  we  found  to 
afford  the  most  trustworthy  evidence  of  disease;  (1)  a  diastolic 
bruit;  (2)  a  systolic  bruit  at  the  apex,  of  very  local  character;  (3) 
a  systolic  bruit  at  the  base,  heard  loudest  below  the  3rd  rib,  and 
relatively  louder  towards  the  right  side  of  the  sternum  than  towards 
the  left  shoulder.  With  reference  to  the  second  class,  the  existence 
of  a  bruit  is  a  pretty  certain  indication  of  valvular  imperfection ; 
but  this  may  be  due  not  so  much  to  change  in  the  structure  of  the 
valve,  as  to  enlargement  of  the  cavities  of  the  heart,  which  has 
altered  the  relation  naturally  existing  between  the  size  and  position 
of  the  aperture  and  that  of  the  valve  which  is  designed  to  close  it. 
When  no  bruit  is  present,  we  must  be  guided  by  the  general  symp- 
toms of  the  case:  venous  congestion  and  a  weak  pulse,  while  the 
heart  is  acting  powerfully,  must,  for  example,  be  taken  as  conclusive 
proof  of  valvular  lesion,  whether  we  hear  a  bruit  or  not. 

At  the  risk  of  some  repetition,  let  us  for  a  moment  consider  the  progress  of  the 
blood  through  the  central  organ.  It  passes  onward  through  the  mitral  valve 
during  the  diastole,  beginning  its  movement  directly  after  the  shock  of  the  apex 
against  the  rib;  it  is  performed  slowly  and  silently,  with  but  little  force;  and  for  a 
diastolic  bruit  to  be  produced,  there  must  be  very  considerable  roughness  or  change 
in  the  form  of  the  orifice,  to  throw  the  blood  into  vibration.  An  anremic  condition 
is  never  sufficient  to  develop  sonorous  vibrations  with  a  healthy  mitral  valve. 
As  soon  as  the  systole  begins,  the  valve-flaps  ought  to  come  together,  to  prevent 
any  blood  from  escaping  in  that  direction;  and  a  systolic  bruit  can  only  be  pro- 
duced by  their  imperfect  closure:  but  as  the  force  with  which  the  ventricle  con- 
tracts is  considerable,  a  very  slight  defect  is  sufficient  to  produce  this  regurgita- 
tion, which  for  some  reason  or  other  very  easily  produces  a  bruit.  It  is  not  the 
roughness  that  occasions  the  murmur  in  this  case,  because  it  is  just  as  distinct 
when  the  valves  cannot  close  perfectly  from  any  other  cause,  such  as  dilatation  of 
the  heart  when  the  flaps  are  too  small  for  the  aperture,  shortening  or  rupture  of 
any  of  the  chordae  tendinece,  &'c.  Its  position  is  remarkably  local,  most  commonly 
between  the  same  ribs  where  the  apex  beat  is  felt,  and  somewhat  nearer  the  ster- 
num; sometimes  in  the  interspace  above:  and  though  localized  to  a  certain  extent, 
by  the  sound  being  more  readily  heard  through  the  interspace,  still  it  has  a  dis- 
tinctness at  one  spot  which  no  other  endocardial  murmur  presents.  From  the 
latter  point  it  is  that  the  diastolic  mitral  murmur  also  proceeds;  but  it  can  be 
traced  onwards  towards  the  centre  of  the  heart. 

Following  the  course  of  the  blood,  we  find  it  passing  through  the  ventricle;  and 
now  commence  the  vibrations  in  anasmic  subjects  which  are  heard  in  the  precor- 
dial space  or  in  the  aorta:  next  it  passes  the  portal  of  the  aorta,  and  if  the  valves 


288  'diseases  of  the  heart. 

be  roughened  or  stiff,  even  healthy  blood  is  thrown  into  vibration,  and  a  bruit  is 
developi  d  which  has  for  its  point  of  greatest  intensity  the  3rd  interspace,  com- 
mencing  before  the  apex  impinges  against  the  thorax,  and  terminating  after  it: 
if  the  blood  be  at  all  altered  by  aiuumia,  this  bruit  crosses  the  sternum,  and  can 
be  heard  on  its  right  side.  As  soon  as  the  systole  is  completed,  the  aortic  valves 
fall  backwards  and  close  in  health:  in  disease  the  adaptation  may  still  be  perfect, 
and  the  2nd  sound  of  the  heart  distinct,  though  a  systolic  aortic  bruit  exist;  but 
their  adaptation  may  be  imperfect,  or  a  perforation  may  exist;  and  then  the  blood, 
in  place  of  being  held  back  by  the  valves,  repasses  into  the  ventricle,  in  conse- 
quence of  the  pressure  exerted  by  the  resiliency  or  contractility  of  the  aorta.  It 
may  have  to  pass  over  stiff  and  rough  valves,  and  be  thrown  into  vibration  as  it 
passes,  or  it  may  pass  through  a  smooth  opening  and  no  bruit  be  developed  at  the 
valve;  but  it  very  soon  encounters  the  current  entering  in  the  opposite  direction 
from  the  auricle,  and  vibration  must  result,  and  a  bruit  be  formed.  A  diastolic 
aortic  murmur  is  therefore  always  audible  at  the  centre,  and  even  onwards  to  near 
the  apex  of  the  heart,  increasing  in  distinctness  as  we  descend;  but  it  may  also  be 
traced  from  the  3rd  interspace. 

The  blood  on  its  return  from  the  veins  next  presents  exactly  similar  relations 
to  the  tricuspid  valve  on  entering  the  right  ventricle  and  the  pulmonic  valves  as 
it  leaves  it;  but  bruits  are  very  seldom  developed  on  this  side  of  the  heart,  except 
when  caused  by  blood-change;  and  then  they  are  heard  much  more  loudly  in  the 
pulmonary  artery  than  elsewhere,  because  at  the  2nd  interspace  is  found  the  most 
superficial  portion  of  the  circuit.  We  know  that  tricuspid  regurgitation  often  take3 
place,  for  we  see  the  pulsation  of  the  jugulars  corresponding  in  time  to  the  systole 
and  apex-beat,  but  it  occurs  without  bruit ;  and  though  this  result  be  no  doubt 
partly  due  to  the  more  feeble  contractions  of  the  right  side,  it  also  depends,  in  all 
probability,  on  the  construction  of  the  valve  being  such  as  to  permit  this  regurgi- 
tation for  the  relief  of  the  circulation:  bruits  at  the  pulmonic  valves,  independent 
of  blood-change,  are  necessarily  rare,  from  the  comparative  infrequency  of  disease 
at  the  root  of  the  pulmonary  artery. 

AVe  have  learnt,  then,  that  a  diastolic  murmur  from  the  apex 
towards  the  centre  of  the  heart,  indicates  very  decided  mitral  dis- 
ease ;  one  from  the  base  towards  the  centre,  imperfect  closure  of 
the  aortic  valves.  We  have  learnt,  too,  that  a  systolic  murmur,  of 
local  character  and  distinctness  towards  the  apex,  may  be  presumed 
to  be  dependent  on  disease  of  the  mitral  valve  in  the  majority  of 
instances,  and  that  a  murmur  heard  between  the  3rd  and  4th  carti- 
lages on  the  left,  traceable  over  the  sternum  to  the  interspace  be- 
tween the  2nd  and  3rd  cartilages  on  the  right  side  of  the  chest,  may 
probably  be  dependent  on  disease  about  the  root  of  the  aorta,  or 
the  aortic  valves;  and  the  more  defined  and  distinct  it  is,  the  more 
likely  is  this  conclusion  to  be  true ;  the  more  diffuse  and  indistinct, 
the  more  care  must  be  taken  before  coming  to  any  judgment  on  the 
subject. 

For  the  purpose  of  diagnosis,  the  sound  is  only  one  element  in  the 
investigation,  which  has  to  be  compared  with  all  the  others,  and  has  to 
be  reconciled  with  them  on  rational  principles,  not  by  forced  and 
overstrained  hypotheses.     The  points  to  be  considered  are, — 

a.  The  pulse.  (1)  It  is  essentially  weak,  often  irregular,  and 
sometimes  almost  imperceptible  in  mitral  insufficiency.  (2)  It  is 
jerky,  thrilling,  and  hammering  in  aortic  insufficiency.  (3)  It  is 
weak  in  cases  of  diastolic  murmur  produced  at  the  mitral  valve, 
because  such  a  condition  is  necessarily  connected  with  mitral  in- 


VALVULAR    LESION.  289 

sufficiency.  (4)  If  it  have  at  all  a  thrilling  character,  "while  also 
firm  and  resisting,  in  cases  of  systolic  murmur  at  the  base,  the  pro- 
bability of  aortic  disease  is  much  increased. 

b.  The  existence  of  hypertrophy  renders  the  diagnosis  of  valvular 
lesion  more  certain.  But  we  sometimes  find  that  dilatation,  without 
corresponding  increase  in  size  of  the  valve-flaps,  renders  them  in- 
adequate to  close  the  aperture.  When  regurgitation,  therefore, 
occurs,  it  is  more  correct  to  speak  of  insufficiency  than  lesion  of  the 
valve,  although  practically  that  insufficiency  depends  in  by  far  the 
larger  number  of  instances  on  actual  disease  of  the  valve-structure, 
and  is  the  result  of  the  lesion,  whether  that  have  originated  sud- 
denly in  rupture,  more  slowly  in  the  changes  consequent  on  inflam- 
mation, or  still  more  slowly  in  chronic  degeneration. 

Shortening  of  the  chordae  tendineae  sometimes  seems  to  produce  an  insufficiency 
of  the  mitral  valve,  which  may  last  only  for  a  short  time.  This  explanation  has 
been  offered  of  the  mitral  murmur  of  chorea,  when  it  has  disappeared  as  the  spas- 
modic muscular  movements  have  ceased.  I  have  observed  a  similar  effect  follow 
on  rheumatic  pericarditis.  An  intense  mitral  murmur  with  evident  regurgitation 
was  heard,  when  the  friction  sound  had  ceased  for  some  weeks,  while  the  patient 
continued  under  observation;  but  at  the  end  of  three  or  four  months,  during  which 
no  treatment  was  pursued,  it  had  entirely  disappeared;  the  heart's  sounds  were 
then  found  perfectly  normal,  and  only  a  suspicion  of  an  adherent  pericardium 
could  be  entertained. 

c.  The  general  aspect  and  history  of  the  patient  serve  to  indicate 
the  probability  of  heart-disease  on  the  one  hand  by  capillary  con- 
gestion, or  blood-changes  on  the  other,  by  an  appearance  of  anocmia. 
The  indications  from  the  venous  circulation  are  also  not  less  valua- 
ble than  the  capillary — jugular  pulsation  as  caused  by  the  blood 
being  thrown  back  at  each  systole  into  the  veins — venous  hum  as 
proving  the  existence  of  blood-change. 

When  the  systolic  murmur  is  heard  towards  the  apex,  a  weak  pulse  confirms 
the  diagnosis  of  mitral  disease:  a  well-filled  pulse,  though  perhaps  a  very  soft  one, 
must  lead  to  grave  doubt  as  to  whether  the  sound  depend  on  mitral  insufficiency; 
and  if  it  be  diffuse,  and  the  aspect  anaemic,  the  rational  explanation  would  seem 
to  be  that  the  sound  is  heard  there,  only  because  of  some  accidental  relation  be- 
tween the  chest  and  the  organs  of  circulation,  by  which  the  sound  of  vibration  of 
blood  is  conveyed  to  the  ear  better  from  the  interior  of  one  of  the  ventricles  than 
from  either  of  the  great  vessels.  Again,  if  there  be  no  anaemia,  but,  on  the  con- 
trary, venous  and  capillary  congestion,  with  jugular  pulsation,  indicating  that  the 
blood  is  thrown  back  from  the  right  side  of  the  heart,  a  full  pulse  might  lead  us 
to  suspect  that  the  sound  was  not  improbably  due  to  disease  of  the  tricuspid  valve. 

In  the  systolic  murmur  at  the  base,  the  history  of  previous  rheumatic  fever,  or 
of  nervous  or  hysterical  symptoms;  the  complaint  of  palpitation,  or  of  cough  and 
dyspnoea;  and  the  aspect,  whether  pallid  or  florid, — help  in  the  determination  of 
what  is  the  value  of  the  bruit.  Only  it  must  be  remembered  that,  begun  by  actual 
alteration  of  the  valve,  it  may  be  exaggerated  by  changes  in  the  condition  of  the 
blood.  We  should  be  mistaken  in  looking  always  for  a  thrill  in  the  pulse,  though 
this  be  not  unfrequent;  because,  in  place  of  its  being  firm,  as  it  generally  becomes 
in  consequence  of  hypertrophy  in  very  marked  aortic  disease,  it  may  be  rendered 
weak  by  dilatation  or  fatty  degeneration :  the  coexistence  of  arcus  senilis,  as  al- 
ready observed,  affords  some  confirmation  to  the  latter  hypothesis. 

In  decided  anaemia  we  are  apt  to  overlook  the  actual  coexistence  of  valvular 

19 


290  DISEASES    OF    THE    HEART. 

lesion.  Tn  hvpertrophy  and  dilatation  we  are  apt  to  assume  its  presence  when 
there  is  merelj  imperfect  closure  and  no  positive  disease:  but  the  latter  is  of 
much  less  moment  as  an  error  in  diagnosis  than  the  former. 

The  absence  or  presence  of  a  hammering  pulse  may  at  once  decide  the  question 
whether  B  diastolic  murmur  be  produced  in  the  mitral  or  in  the  aortic  valves. 

When  a  double  Bonnd  is  heard,  the  history,  the  pulse,  and  the  aspect  of  the  pa- 
tient oupht  never  to  permit  the  existence  of  a  doubt  whether  it  be  endocardial  or 
exocardial  even  in  cases  in  which  the  character  of  the  sound  is  not  sufficient  to 
determine  the  question;  and  here,  again,  as  between  a  double  sound  produced  in 
the  aortic  and  a  double  sound  produced  in  the  mitral  aperture,  the  pulse  is  one  of 
the  best  aids  to  forming  a  correct  opinion. 

When  all  has  been  done  that  can  be  done  towards  forming  an 
accurate  diagnosis,  many  cases  will  remain  in  which  the  judgment 
is  perplexed  and  the  decision  uncertain,  many  in  which  the  conclu- 
sion has  been  absolutely  false:  but  the  mind  best  trained  to  ex- 
amining and  weighing  the  facts  of  each  case,  and  the  ear  most  ac- 
customed  to  discriminate  and  individualize  the  sounds,  will  be  least 
frequently  in  error  in  obscure  cases — will  also  be  most  often  right 
in  those  of  every-day  experience,  which  even  in  their  simplest  form 
present  to  the  careful  physician  so  perplexing  a  problem.  We  need 
only  here  allude  to  some  of  those  loud  musical  sounds  heard  at 
times  some  distance  from  the  patient,  which  from  their  very  inten- 
sity cannot  be  localized  at  all:  for  them  the  stethoscope  need  not 
exist — they  must  be  judged  of  solely  by  general  symptoms.  Cases, 
on  the  other  hand,  occasionally  present  themselves  which  are  too 
few  to  be  made  the  basis  of  any  diagnostic  rules,  and  yet  too  curi- 
ous to  be  passed  over:  these  are  cases  in  which  the  arterial  and 
venous  currents  get  mixed  through  some  congenital  malformation,  the 
circulation  of  the  foetus  being  to  a  certain  extent  continued  after 
birth.  The  blueness  of  the  skin,  without  appreciable  obstruction 
to  the  respiration,  and  the  long  continuance  of  the  symptom — its 
persistence,  in  fact,  from  birth,  or  at  least  childhood — serve  suffi- 
ciently to  mark  them  off  as  a  set  of  cases  standing  alone. 

Disease  of  the  mitral  valve  may  be  traced  in  a  large  number  of 
cases  to  rheumatic  fever.  This  seems  to  be  the  point  on  which 
endocarditis,  accompanying  that  disease,  most  readily  fastens  in  the 
first  instance;  when  the  first  seizure  is  severe,  or  subsequent  attacks 
occur,  the  aortic  valves  are  usually  also  implicated.  The  systolic  mur- 
mur is  so  readily  produced,  that  very  slight  changes  in  the  form  of 
the  mitral  valve  are  indicated,  though  the  pulse  be  for  a  long  time 
scarcely  affected,  and  the  circulation  undisturbed:  when  the  change 
is  originally  greater,  or  repeated  attacks  of  inflammation  have  seri- 
ously damaged  the  valve,  the  circulation  is  impeded,  because  the 
whole  contents  of  the  ventricle  are  not  propelled  through  the  aorta; 
and  the  current  is,  consequently,  both  smaller  and  weaker;  but, 
besides  this,  the  blood  which  escapes  through  the  mitral  orifice  is 
driven  back  upon  the  lungs,  producing  congestion,  and  giving  rise 
to  imperfect  oxygenation:  hence  we  have  the  two  symptoms  of 
feeble  pulse  and  dusky  complexion. 


VALYULAR   LESION.  291 

In  the  further  progress  of  disease  the  left  side  of  the  heart  be- 
comes dilated,  and  its  walls  hypertrophied;  sometimes  the  one,  and 
sometimes  the  other  condition  prevailing,  but,  as  a  general  rule, 
the  dilatation  exceeding  the  hypertrophy.  The  diastolic  mitral 
murmur  is  usually  developed  when  the  hypertrophy  is  greater  than 
the  dilatation.  The  heart's  action  becomes  irregular  when  the 
dilatation  is  in  excess;  and  ultimately  tumultuous  action  is  brought 
on  by  some  sudden  strain,  when  the  imperfect  contractions  of  the 
ventricle,  and  the  distended  condition  of  the  auricle,  are  such  that 
no  bruit  is  produced  at  all.  In  these  cases  the  mitral  disease  may 
be  entirely  overlooked;  and  if  the  heart  should  happen  to  be  much 
overlapped  by  the  lung,  so  that  its  increase  in  size  is  not  observed, 
the  irregular  action  and  feeble  pulse  may  be  set  down  as  the  result 
of  degeneration,  and  the  imminent  danger  of  the  patient  unfore- 
seen. 

Disease  of  the  aortic  valves  is  very  frequently  a  slow  process, 
analogous  to  the  atheromatous  disease  of  the  root  of  the  aorta;  the 
two  conditions  being,  in  fact,  very  often  found  together:  but  it  is 
also  the  result  of  endocardial  inflammation,  especially  when  asso- 
ciated with  mitral  disease.  Simple  roughening,  or  thickening  of 
the  valves,  such  as  does  not  prevent  tolerably  perfect  closure,  with- 
out regurgitation,  is  not  of  itself  a  disease  of  much  moment;  but 
the  bruit  heard  over  these  valves  during  the  contraction  of  the 
heart  is  of  much  importance  from  its  being  an  early  index  of  the 
tendency  to  atheroma:  by  destroying  the  elasticity  of  the  aorta, 
this  form  of  degeneration  produces  hypertrophy,  and,  when  affect- 
ing the  arteries  of  the  brain,  leads  to  disturbed  circulation  within 
the  cranium,  and  ultimately  to  apoplexy. 

The  valvular  disease  comes  to  be  of  real  importance  when  regur- 
gitation is  permitted:  a  permanent  obstacle  to  the  completeness  of 
the  circulation  is  established  by  a  portion  of  the  blood  propelled 
during  each  systole  returning  into  the  cavity;  and  to  counteract 
this  defect  hypertrophy  is  soon  established:  but  the  constant  and 
excessive  distention  during  the  diastole  also  produces  dilatation, 
and  it  is  in  cases  of  double  aortic  murmur  that  the  largest  hearts 
are  usually  found.  The  effect  of  the  afflux  and  reflux  of  the  blood 
upon  the  character  of  the  pulse  in  these  cases  is  most  striking. 
Patency  of  the  valve,  while  very  generally  dependent  on  rigidity 
or  irregular  form  of  the  flaps  interfering  with  their  mutual  adapta- 
tion, is  also  known  as  a  result  of  accident  when  one  of  the  valves 
is  torn,  or  of  ulceration:  the  absence  of  systolic  murmur  might  lead 
to  a  suspicion  that  these  last  were  the  causes  of  the  diastolic  mur- 
mur. It  very  seldom  happens  that  we  know  that  the  heart  was 
free  from  disease  before  some  unusual  strain,  and  it  is  dangerous  to 
conclude  from  the  patient's  statement  that  rupture  has  taken  place 
on  such  an  occasion ;  in  very  severe  disease  of  the  heart,  of  long 
standing,  the  patient  is  often  utterly  unconscious  of  its  existence 
till  some  such  event  call  his  attention  to  it.     Imperfect  closure  of 


202  DISEASES   OF    THE    IIEART. 

the  aortic  valves  is  not  unfrequently  caused  by  dilatation  of  the 
vessel,  while  the  valves  themselves  are  free  from  disease.  The 
same  dilatation  at  a  more  distant  part  of  the  vessel  occurs  as  aneu- 
rism of  the  arch,  which  is  invariably  attended  with  hypertrophy, 
and,  to  an  inexperienced  observer,  may  present  many  of  the  phe- 
nomena of  valvular  lesion. 

Among  the  associations  of  cardiac  disease  some  may  be  traced 
to  it  as  their  cause,  more  or  less  remote:  of  these  dropsy  is  perhaps 
the  most  frequent,  both  in  its  generic  form  as  anasarca,  and  as  pas- 
sive effusion  into  various  cavities.  Bronchitis,  or  rather  bronchor- 
rhoea,  results  from  the  obstruction  to  the  pulmonic  circulation,  giving 
rise  to  congestion  and  oedema  of  the  lungs;  and,  for  the  same  rea- 
son, simple  bronchitis  from  exposure  is  more  severe  in  persons  with 
disease  of  the  heart.  Haemoptysis  occurs  in  consequence  of  more 
decided  congestion  or  plethora  of  the  pulmonary  vessels.  Epistaxis 
is  perhaps  also  excited  by  cardiac  disease.  Disordered  cerebral 
circulation  produces  those  affections  which  we  have  denominated 
functional  disturbance  of  the  brain,  or  may  lead  to  epileptic,  and 
especially  to  apoplectic  seizures.  Congestion  of  the  liver  is  often 
manifested  in  jaundice;  the  same  condition  of  kidney  leads  to  the 
transient  presence  of  albumen  in  the  urine. 

Other  associations  are  rather  to  be  regarded  as  causes  of  disease 
of  the  heart;  such  as  rheumatism,  pleurisy,  albuminuria,  and  that 
form  of  mal-nutrition  which  produces  atheroma:  in  the  former  we 
expect  to  find  inflammatory  changes,  in  the  latter,  diseases  of  chronic 
form;  the  one  more  frequent  in  early  life,  the  other  found  at  later 
periods.  Similarly,  each  of  the  forms  of  cardiac  disease  tend  mutu- 
ally to  develop  each  other.  Not  only  does  the  valvular  lesion  lead 
to  hypertrophy  and  dilatation,  but  these,  in  their  turn,  serve  to  in- 
crease the  valvular  imperfection.  Partial  adhesions  of  the  pericar- 
dium become  very  often  a  cause  of  hypertrophy,  while  its  complete 
adhesion  is  more  commonly  followed  by  dilatation  or  atrophy. 
Permanent  albuminuria  is  associated  alike  with  hypertrophy  or  di- 
latation, and  with  degeneration  of  the  valves ;  but  while  it  seems 
to  be  a  direct  cause  of  the  hypertrophy,  its  association  with  the 
other  forms,  is  rather  secondary  and  concomitant;  it  bears,  how- 
ever, some  very  close  relations  to  the  inflammatory  lesion,  pericar- 
ditis especially  being  frequently  found  in  the  course  of  Bright's  dis- 
ease. Inflammation  of  the  pleura,  is  liable  to  spread  to  the  peri- 
cardium, but  seldom  affects  the  lining  membrane  or  valves  of  the 
heart. 


293 


CHAPTER  XXIIL 

DISEASES    OF   THE   BLOOD-VESSELS. 

DiV.  I. — Diseases  of  Arteries — Aneurism — §  1,  Superficial  Aneu- 
rism— §  2,  Thoracic  Aneurism — §  3,  Abdominal  Aneurism. 

Div.  II. — Diseases  of  Veins — Phlebitis — §  1,  Pysemia — §  2,  Phleg- 
masia Dolens — §  3,  Capillary  Phlebitis. 

Division  I. — Diseases  of  Arteries. 

In  pathology  we  become  acquainted  with  inflammation  vf  the 
lining  membrane  of  the  arteries,  but,  as  yet,  it  has  received  no 
clinical  history:  its  occurrence  is,  indeed,  so  rare,  that  the  obser- 
vation which  may  associate  the  history  with  the  post  mortem  ap- 
pearances must  be  rather  a  matter  of  accident  than  one  which  can 
be  fairly  regarded  as  a  subject  of  study.  It  is  certainly  very  re- 
markable that  the  inflammatory  action  so  often  observed  on  the 
valves  of  the  heart,  and  not  unfrequently  associated  with  patches 
of  inflammation  on  the  endocardial  membrane,  should  so  rarely  ex- 
tend to  the  arteries. 

Aneurism  is,  in  its  early  beginnings,  also  unknown  to  us  in  a  clini- 
cal point  of  view;  there  is  nothing  in  the  history  of  its  development 
characterizing  the  disease  in  such  a  manner  as  to  be  of  avail  in 
diagnosis.  There  is  little  to  be  learned  regarding  it  beyond  the 
fact  that  a  swelling  has  been,  at  some  period,  discovered  by  the 
patient,  or  that  symptoms  have  occurred  which  might  be  explained 
by  the  hypothesis  of  aneurism,  when  no  swelling  has  been  observed. 

Its  diagnosis  resolves  itself  into  a  consideration  of  the  circum- 
stances  proving  the  existence  of  a  tumour,  of  the  evidence  of  its 
pulsation,  and  of  the  disturbances  produced  in  the  circulation, 
especially  in  the  development  of  an  arterial  bruit.  When  these 
points  can  be  made  out  distinctly  there  is  no  difficulty  in  forming  a 
correct  opinion  of  the  case.  In  many  instances,  however,  from  the 
position  of  the  diseased  artery,  the  information  is  obtained  with 
difficulty,  or  is  very  imperfect;  and  then  careful  examination  and 
correct  reasoning  can  alone  conduct  us  to  a  trustworthy  explanation 
of  the  phenomena:  a  hasty  observer  is  liable  either  to  overlook  the 
disease  altogether,  or  to  misinterpret  the  meaning  of  the  symptoms 
which  he  has  discovered. 

§  1.  Superficial  Aneurism. — When  occurring  in  a  tolerably 
superficial  artery,  the  disease  commonly  falls  under  the  care  of  the 
surgeon.  Mistakes  are  less  likely  to  occur  than  when  it  is  deep- 
seated:  the  pulsation  and  the  bruit  are  both  pretty  readily  made 
out;  and  when  by  pressure  on  the  artery,  at  the  proximal  side  of 


204  DISEASES    OF    THE    BLOOD-VESSELS. 

the  tumour,  it  collapses,  and  is  rendered  flaccid  by  the  sac  becoming 
partially  emptied,  the  diagnosis  is  simple  and  distinct.  In  a  more 
advanced  stage,  when  from  large  deposits  in  its  interior  the  sac  has 
become  hard  and  firm,  it  is  especially  important  to  note  that  the 
pulsation  is  felt  when  a  finger  is  placed  on  each  side,  because  an 
clastic  tumour  lying  over  an  artery  very  generally  pulsates  out- 
wards, but  not  so  as  to  be  felt  transversely  across  the  course  of  the 
vessel.  The  arterial  bruit  may  also  be  simulated  by  the  pressure 
of  a  tumour  on  a  perfectly  healthy  vessel,  especially  in  those  con- 
ditions of  blood  which  embarrass  the  diagnosis  of  diseases  of  the 
heart,  by  producing  cardiac  murmurs.  A  tumour  lying  over  an 
artery  must,  from  its  very  position,  be,  to  a  certain  extent,  move- 
able, or  at  least  its  point  of  attachment  to  the  deeper  tissues  does 
not  correspond  with  the  known  course  of  the  artery;  and  this 
serves  as  a  further  guide  in  diagnosis. 

In  superficial  aneurism  we  may  sometimes  be  guided  by  the 
history  of  sudden  appearance  after  a  strain,  and  the  mode  in  which 
it  first  revealed  itself  to  the  patient's  consciousness;  but  to  these 
much  importance  cannot  attach.  It  seems  scarcely  possible  that 
cellular  inflammation  and  abscess  lying  over  an  artery  should  be 
mistaken  for  aneurism. 

§  2.  Thoracic  Aneurism. — It  is  unnecessary  to  repeat  the  indi- 
cations by  which  we  may  arrive  at  the  conclusion  that  a  tumour  of 
some  sort  exists  in  the  cavity  of  the  chest  (see  Chapter  XX.,  §  10;) 
we  have  only  to  consider  here  by  what  circumstances  we  may  be 
led  to  believe  that  it  is  of  the  nature  of  aneurism.  And  in  forming 
this  judgment  the  pathological  facts  connected  with  the  disease  are 
not  to  be  forgotten:  such  as  its  relative  frequency  at  the  commence- 
ment and  arch  of  the  aorta,  and  the  consequent  probability  of  its 
being  found  at  the  upper  and  front  part  of  the  chest,  its  tendency 
to  cause  absorption  or  erosion  of  tissues  by  pressure,  and  hence  the 
frequency  with  which  it  is  attended  by  pain;  hence,  too,  its  termi- 
nation by  hemorrhage  before  it  has  attained  any  such  dimensions 
as  are  seen  in  cases  of  malignant  growth:  nor  may  we  forget  the 
necessary  disturbance  of  the  circulation,  and  the  constant  accom- 
paniment of  hypertrophy  of  the  heart. 

In  the  dysphagia  or  dyspnoea  caused  by  its  pressure,  which  serves 
in  many  instances  first  to  call  our  attention  to  its  presence,  it  does 
not  differ  from  other  forms  of  tumour :  but  from  the  position  of  the 
aorta  they  are  perhaps  more  common  and  earlier  in  their  appear- 
ance, the  cough  in  particular  having  a  remarkable  metallic  clang. 
Aneurism  is  much  more  liable  to  interfere  with  the  arterial  circula- 
tion, morbid  growth  with  the  venous;  in  the  one  a  difference  can 
frequently  be  observed  between  the  pulse  at  the  two  wrists,  in  the 
other  we  are  more  likely  to  find  tortuous  veins  over  the  neck  and 
thorax:  but  it  may  be  worth  mentioning  that  oedema  of  the  arms, 
when  the  circulation  is  obstructed,  sometimes  renders  the  observa- 


THORACIC   ANEURISM.  295 

tion  of  the  pulse  fallacious.  It  would  seem,  too,  that  relief  from 
the  pressure,  by  change  of  posture,  is  more  decided  in  the  case  of 
aneurism  than  of  other  thoracic  tumours;  but  in  all  cases  it  is 
usually  found  at  some  period  of  their  history  that  a  prone  position 
is  preferred  to  any  other. 

The  situation  in  which  aneurism  is  commonly  found,  towards  the 
upper  and  front  part  of  the  chest,  may  lead  to  its  being  detected 
by  percussion  and  auscultation;  the  dulness  is  limited,  and  is  not 
complete;  and  though  greater  on  one  side  than  the  other,  unlike 
the  consolidation  of  tubercle,  it  is  most  distinct  close  to  the  sternum. 
Solid  growth  in  the  anterior  mediastinum  is  not  limited  to  the  upper 
part  of  the  sternum,  but  the  dulness  extends  all  the  way  down;  it 
is  also  more  complete.  The  earliest  auscultatory  phenomenon  is  a 
jogging  sound,  which  can  be  heard,  and  seems  to  be  felt,  when 
listening  over  the  site  of  the  tumour:  it  is  probably  produced  by 
its  actually  impinging  on  the  parietes.  In  other  instances  an  arte- 
rial bruit  or  whiz  is  heard  there  much  more  distinctly  than  else- 
where: it  is  notunfrequently  audible  also  in  the  precordial  region; 
and  hence,  with  the  natural  accompaniment  of  hypertrophy,  may 
be  wrongly  attributed  to  valvular  disease  of  the  heart. 

In  its  further  progress  the  aneurism  causes  absorption  of  the  in- 
tervening tissues,  becoming  gradually  more  superficial:  the  bony 
structures  soften,  and  the  pulsation  is  readily  observed  externally. 
Pain  is  necessarily  excited  by  this  action,  and  has  a  gnawing  cha- 
racter: the  whizzing  sound  is  rarely  wanting.  It  is  not  easy  to 
determine  what  circumstances  give  rise  to  the  production  of  bruit 
in  some  cases  and  not  in  others ;  probably  they  are  connected  with 
the  form  of  the  tumour  and  the  condition  of  its  interior.  An  ar- 
tery pretty  evenly  dilated  will  only  give  rise  to  the  jogging  sound 
already  spoken  of  in  consequence  of  its  contact  with  the  ribs ;  while 
one  in  which  a  distinct  pouch  has  formed,  or  which  is  lined  in  its 
interior  by  uneven  layers  of  lymph,  will  throw  the  blood  into  sono- 
rous vibrations  as  it  enters  or  leaves  the  enlarged  portion. 

§  3.  Abdominal  Aneurism. — Abdominal  pulsation  has  a  very 
vague  significance,  and  the  student  cannot  be  too  careful  to  avoid 
the  mistake  of  supposing  it  to  be  constantly  or  even  frequently  an 
evidence  of  aneurism.  It  is  of  common  occurrence  among  nervous, 
hysterical,  and  dyspeptic  patients,  and  means  nothing  generally, 
when  unaccompanied  by  the  evidence  of  disturbed  circulation  which 
is  afforded  by  the  existence  of  hypertrophy  of  the  heart.  On  the 
other  hand,  simple  hypertrophy  very  often  communicates  its  pulsa- 
tion through  the  diaphragm  to  the  abdominal  viscera,  when  there  is 
no  enlargement  of  the  descending  aorta :  and  in  such  cases  if  anae- 
mia lead  to  the  development  of  bellows-murmur,  the  mistake  of  sup- 
posing both  pulsation  and  bruit  to  be  dependent  on  aneurism  is  very 
likely  to  be  made. 

The  decided  indications  of  abdominal  aneurism  are  the  follow- 


29G  DISEASES   OF   THE   BLOOD-VESSELS. 

in^: — The  tumour  corresponds  in  position  and  direction  to  the 
known  course  of  the  aorta  or  iliacs ;  its  attachments  are  firm,  and 
it  is  but  slightly  movable;  pulsation  is  felt  in  a  lateral  direction  as 
the  patient  lies  on  his  back,  and  this  pulsation  does  not  disappear 
on  change  of  posture;  a  local  bruit  is  audible,  which  cannot  be 
heard  over  the  precordial  region. 

Any  tumour  lying  upon  arteries  of  the  size  of  the  aorta  and  iliacs 
must  necessarily  convey  a  sense  of  pulsation  in  an  upward  direc- 
tion,— from  the  artery,  through  the  tumour,  to  the  finger  placed  op- 
posite to  it;  but  it  does  not  pulsate  laterally,  and  when  a  finger  is 
placed  on  each  side  the  difference  is  unmistakable.  It  is  also  to  be 
remarked  that  in  change  of  posture  the  altered  relations  of  the  tu- 
mour and  the  vessel  will  cause  the  pulsation  to  disappear  in  the  one 
case,  while  it  remains  unaffected  in  the  other.  The  arterial  bruit 
cannot  be  much  relied  on,  especially  if  there  be  concomitant  ansemia. 

Division  II. — Diseases  of  Veins. 

As  in  the  diseases  of  arteries,  we  meet  with  inflammation  and 
dilatation  of  the  veins;  but  in  this  part  of  the  vascular  apparatus 
the  inflammatory  action  is  a  very  common  and  very  serious  disor- 
der ;  the  enlargement  is  of  very  secondary  importance.  Varicose 
veins,  indeed,  even  if  they  were  not  entirely  regarded  as  a  surgical 
disease,  could  hardly  claim  any  place  in  a  treatise  on  diagnosis, 
and  we  shall  therefore  confine  our  attention  to  phlebitis. 

The  lining  membrane  of  the  veins  would  seem  to  take  on  inflam- 
matory action  in  connexion  with  two  very  distinct  conditions  of  the 
contained  blood,  and  it  cannot  be  doubted  that  the  inflammation  is 
itself  of  a  different  kind  in  each.  In  the  one  there  is  a  tendency 
to  the  formation  of  pus,  in  the  other  fibrinous  clots  are  formed, 
which  more  or  less  plug  up  and  obstruct  the  veins.  This  subject 
has  of  late  years  been  very  closely  investigated,  and  opinions  are 
yet  much  divided  on  the  sequence  of  events.  With  reference  to 
diagnosis  we  have  only  to  do  with  the  conditions  as  seen  at  the 
bedside,  and  the  facts  elicited  in  the  history  of  each:  the  first^  be- 
comes known  to  us  by  the  existence  of  a  form  of  blood-poisoning; 
the  second  is  familiar  to  us  in  phlegmasia  dolens. 

§  1.  Pi/cemia,  or  purulent  contamination  of  the  blood,  has  already 
formed  the  subject  of  a  previous  section.  (Chap.  VIII.,  §  5.)  When 
occurring  in  a  patient  who  has  an  open  suppurating  wound,  it  might 
be  alleged  that  the  pus  has  actually  entered  into  the  open  mouths 
of  vessels:  unphilosophical  as  this  view  must  appear,  it  is  evidently 
wholly  inapplicable  to  those  cases  in  which  suppuration  has  been 
going  on  in  a  closed  cavity,  whether  serous  or  synovial,  or  even  in 
one  formed  by  the  artificial  walls  of  an  abscess:  and  it  is  equally 
untrue  of  pynemia  supervening  upon  diffuse  cellular  inflammation. 
In  such  cases  we  cannot  doubt  that  the  disease  has  commenced  by 


PHLEBITIS.  297 

inflammation  of  a  suppurative  kind  attacking  the  lining  membrane 
of  the  vessel,  whence  the  pus  mingling  with  the  blood  is  carried 
forward  into  the  current  of  the  circulation.  With  an  open  wound 
its  advent  is  marked  by  shivering,  followed  by  perspiration;  and  we 
may  justly  conclude  that  in  the  other  instances  the  same  phenome- 
na do  attend  it,  but  here  they  are  obscured  by  the  previous  existence 
of  rigor,  and  the  liability  to  its  recurrence  when  suppuration  has 
commenced:  hence  it  is  not  till  the  prolonged  sweating  of  pyaemia, 
and  the  secondary  inflammation  of  internal  organs  have  declared 
themselves,  that  we  can  have  any  certain  evidence  of  suppurative 
phlebitis  having  taken  place. 

One  point  deserves  attention,  that  the  fact  of  empyema  having 
followed  pleurisy,  of  suppuration  having  occurred  in  synovitis,  of  a 
large  suppurating  abscess  having  formed,  or  of  the  existence  of 
diffuse  cellular  inflammation,  all  alike  point  to  a  certain  crasis  in 
the  blood  which  predisposes  to  suppurative  phlebitis,  and  that  this 
is  only  a  further  development  of  the  same  tendency  to  the  trans- 
formation of  effused  plasma  into  pus. 

§  2.  Phlegmasia  Dolens  is  seen  in  its  most  characteristic  form  in 
women  after  delivery ;  but  it  also  occurs  not  unfrequently  in  anae- 
mic or  chlorotic  females:  if  it  ever  exist  in  males,  it  is  certainly 
very  rare.  It  is  marked  by  pain  and  swelling  of  some  portion  of 
the  leg,  or  even  of  the  entire  limb,  which  has  a  blanched,  bloodless 
aspect;  it  is  firm  and  elastic,  and  except  in  the  absence  of  redness, 
much  resembles  the  condition  of  erythema;  it  has  not  the  hardness 
of  erysipelas,  nor  the  doughy  feeling  of  anasarca.  At  the  lower 
part  of  the  limb,  beyond  the  limits  of  tension  and  tenderness, 
oedema  may  be  readily  recognised  by  pitting  on  pressure ;  and  in- 
deed there  is  a  certain  amount  of  serous  effusion  throughout,  which 
is  caused  by  the  obstruction  offered  to  the  return  of  the  blood 
through  the  inflamed  vein:  this  combination  of  inflammation  and 
oedema  is  that  which  gives  its  peculiar  features  to  the  disease. 

Occasionally  its  characters  are  much  more  local,  only  affecting 
for  example  the  calf  of  the  leg;  and  then  the  collateral  circulation 
prevents  the  serous  exudation  from  being  so  distinct.  Above  the 
seat  of  swelling,  pain  may  be  traced  for  some  distance  in  the  course 
of  the  emergent  vein ;  and  when  superficial,  as  in  the  ham  or  the 
groin,  a  distinct  hard  knotted  cord  may  be  readily  felt  with  the 
finger,  which  persists  long  after  the  acute  symptoms  have  subsided. 
The  seizure  is  always  a  sudden  one,  and  has  no  history  beyond  that 
of  its  being  found  in  the  associations  indicated  above. 

Its  common  name  of  "white  leg"  sufficiently  discriminates  it  from  erythema 
nodosum  or  diffuse  cellular  inflammation,  and  its  hardness  and  tension  cannot 
lead  to  the  mistake  of  supposing  it  to  be  mere  muscular  rheumatism.  In  some  in- 
stances oedema  with  much  tension,  especially  when  one  leg  only  is  affected,  presents 
characters  of  superficial  tenderness  not  unlike  phlegmasia  dolens ;  but  it  is  always 
readily  to  be  discriminated,  by  its  commencing  at  the  ankle,  gradually  extending 
upwards,  and  being  always  associated  with  venous  congestion ;  while  the  swelling 


298  DISEASES    OF    THE   BLOOD-VESSELS. 

of  phlebitis  begins  in  the  fleshy  part  of  the  limb,  and  is  never  discoloured  by  tur- 
gid blood-vessels. 

A  condition  precisely  similar  maybe  sometimes  seen  in  the  arm  as  a  conse- 
quence of  blood-letting  when  the  lining  membrane  of  the  vein  is  irritated  by  the 
lancet,  but  it  is  usually  associated  with  more  or  less  of  diffuse  inflammation. 

§  3.  Capillary  Phlebitis. — At  post-mortem  examinations  some 
of  the  internal  organs  occasionally  present  appearances  which  have 
led  to  their  being  said  to  be  the  seat  of  capillary  phlebitis.  The  name 
sufficiently  indicates  the  nature  of  the  lesion ;  an  exudative  inflam- 
mation attacking  the  interior  of  the  capillary  vessels,  and  plugging 
them  up  with  fibrin.  It  seldom  passes  to  vessels  of  large  size.  Its 
clinical  history  is  unknown,  and  it  is  even  difficult  to  conceive  how, 
in  the  majority  of  instances,  it  could  be  discriminated  by  any  signs 
during  life  from  other  inflammations  of  the  same  organ. 

Phlebitis  ending  in  occlusion  of  vessels  will  for  a  time  interfere  with  the  circu- 
lation through  the  organs  in  which  the  veins  originate;  but  their  anastomosis 
throughout  the  body  is  so  extensive,  that  the  obstacle  is  very  soon  overcome  by 
the  blood  being  conveyed  through  some  other  channel.  The  only  case  in  which  I 
have  seen  very  serious  or  rather  fatal  results,  was  one  in  which  the  inferior  cava 
was  obstructed,  and  nature  was  unable  perfectly  to  establish  the  circulation  through 
the  tortuous  vessels,  which,  however,  carried  a  very  large  portion  of  the  blood  from 
the  lower  extremities  into  the  superior  cava. 


299 


CHAPTER  XXIV. 

DISEASES   OF   THE   MOUTH   AND    PHARYNX. 

Tlieir  Association  with  Diseases  of  the  Larynx — §  1,  Of  the  Mouth — 
Glossitis — Ulcers  and  Aphthae — Oancrum  Oris — §  2,  Of  the 
Fauces — Quinsy — Enlarged  Tonsils — Ulcerations — §  3,  Of  the 
Glands — Mumps. 

The  diseases  of  the  mouth  and  pharynx  do  not  present  many 
questions  of  interest  in  a  diagnostic  point  of  view.  The  parts  are 
readily  examined,  and  simple  inspection  is  generally  sufficient  to 
determine  the  seat  of  the  affection  and  the  nature  of  the  disease. 
It  is  not  our  object  to  give  a  history  of  pathological  states;  but 
merely  to  point  out  the  distinctive  signs  and  symptoms  by  which 
these  states  may  be  recognised. 

The  complaint  of  the  patient  is  of  soreness  in  the  mouth  or  throat, 
and  of  difficulty  in  taking  food.  Conjoined  with  this  there  may  or 
may  not  be  symptoms  referrible  to  the  entrance  of  the  windpipe, 
hoarseness  or  aphonia,  harsh  sound  or  difficulty  in  breathing.  The 
continuity  of  surface,  as  already  mentioned  in  speaking  of  diseases 
of  the  respiratory  organs,  often  leads  to  an  extension  of  inflam- 
matory-action from  the  one  set  of  organs  to  the  other;  and  to  this 
fact  very  often  the  affections  of  the  pharynx  owe  their  importance 
and  significance. 

In  complex  cases  it  is  very  desirable  to  make  out,  if  possible, 
whether  the  difficulty  in  swallowing  were  preceded  or  even  accom- 
panied from  the  very  first,  by  cough  or  difficulty  in  breathing;  as 
the  disease  is  always  of  graver  import,  which,  commencing  in  the 
larynx,  produces  a  difficulty  in  swallowing,  merely  as  a  subsidiary 
affection,  than  one  which  has  its  original  seat  in  the  pharynx.  In 
simpler  cases  little  is  learnt  from  the  history  beyond  its  duration 
and  the  occurrence  of  a  febrile  attack  in  its  commencement;  points 
which  may  serve  to  correct  a  faulty  diagnosis,  but  are  rarely  es- 
sential to  its  accuracy. 

The  difficulty  in  swallowing  may  be  referred  to  a  point  below  the  inlet  of  the 
pharynx,  and  may  be  due  to  disease  situated  lower  down,  such  as  stricture  of  the 
oesophagus  or  pressure:  but  inspection  of  the  fauces  should  never  be  omitted,  as 
it  may  reveal  deep-seated  ulceration  of  the  pharynx  as  the  cause  of  this  sensation. 
Thickness  of  speech  will  always  result  from  obstruction  about  the  fauces  ;  but  it 
is  very  different  from  the  hoarseness  or  aphonia  of  laryngitis:  the  mistake  is  only 
important  inasmuch  as  it  gives  rise  to  false  alarm,  and  to  treatment  unnecessarily 
active  and  severe.  It  is  unnecessary  here  to  revert  to  the  means  of  distinguishing 
laryngitis  from  pressure  on  the  trachea.     (See  Chap.  XX.,  $  1  and  \  10.) 

The  appearances  divide  themselves  into  redness,  swelling,  ulce- 
ration, and  aphthse;  each  of  which  may  be  recognised  singly  or  in 
groups  over  different  portions  of  the  mouth  and  fauces. 


300  DISEASES    OF    THE   MOUTH   AND   PHARYNX. 

§  1.  As  affecting  the  Mouth. — Redness  and  swelling  of  the 
tongue  indicate  glossitis;  at  all  times  a  rare  disease,  and  now  al- 
most unknown,  since  the  absurdities  of  mercurial  ptyalism  have 
been  abandoned.  When  such  symptoms  are  present,  this  must  not 
fail  to  be  inquired  into;  but  it  is  to  be  remembered  that  the  quan- 
tity of  mercury  taken  is  no  criterion  of  its  effect,  for,  in  peculiar 
constitutions  or  conditions  of  the  system,  they  are  by  no  means  pro- 
portional to  each  other,  and  there  are  even  cases  of  spontaneous 
ptyalism.  We  find  a  pretty  safe  indication  in  the  fetor  of  the 
breath  accompanying  mercurial  salivation.  Yet  even  such  a  point 
as  this  requires  both  experience  and  accuracy  of  observation.  I 
have  known  the  odour  of  sloughing  ulceration  mistaken  for  mer- 
curial fetor. 

The  tongue  is  also  often  affected  with  simple  ulceration,  or  co- 
vered with  aphthae.  Both  of  these  ought  to  be  regarded  as  con- 
stitutional states:  even  when  ulceration  seems  to  be  directly  caused 
by  the  edge  of  a  broken  tooth,  its  real  history  is  probably  a  con- 
dition of  depraved  nutrition  ;  and  this  is  confirmed  by  the  occasional 
appearance  of  ulceration  along  the  edge,  when  no  such  exciting 
cause  is  present.  Aphthae  of  the  tongue  are  much  more  numerous 
than  points  of  ulceration;  they  have  an  appearance  of  elevation 
rather  than  depression,  look  whiter  and  more  solid,  while  ulcers  are 
hollow,  and  filled  with  fluid  secretion:  spots  of  ulceration  are  apt 
to  follow  on  aphthae  when  the  white  crust  is  detached,  but  the  ge- 
neral aphthous  state  is  still  sufficiently  marked.  Both  occur  much 
more  commonly  in  childhood  than  in  adult  life:  ulceration  is  evi- 
dently allied  to  that  condition  which  gives  rise  to  cutaneous  dis- 
orders, especially  impetigo ;  aphthae,  on  the  other  hand,  point  more 
directly  to  the  mucous  membrane.  In  infants  the  disease  is  known 
as  "  thrush,"  and  is  always  associated  with  intestinal  disorder;  in 
adults  it  is  most  frequently  met  with  in  the  last  stages  of  ulceration 
of  the  bowels,  preceded  by  a  red  and  glazed  tongue,  or  when  diar- 
rhoea occurs  as  one  of  the  signs  of  general  exhaustion. 

Ulceration  is  at  times  met  with  on  the  lips  and  the  gums,  or  the 
inside  of  the  cheek ;  in  which  situations  aphthae  are  less  common. 
On  the  gums  it  is  important  to  distinguish  simple  ulceration 
from  that  which  is  produced  by  mercury ;  the  correspondence  of 
ulcers  on  the  lips  and  cheeks  would  tend  to  prove  that  its  origin 
was  not  of  this  specific  character.  One  form  of  ulceration  of  the 
cheek  is  seen  in  childhood,  which  in  its  milder  form  may  be  called 
sloughing  ulcer,  in  its  more  severe  form  has  obtained  the  name  of 
cancrum  oris.  It  is  characterized  by  foul,  unhealthy  secretion, 
and  rapid  tendency  to  spread:  in  the  worst  cases  destroying  the 
cheek  and  side  of  the  face,  and,  in  all,  producing  a  large  unhealthy 
sore.     There  is  no  doubt  that  this,  too,  is  constitutional. 

§  2.  M  the  Entrance  of  the  Fauces. — The  morbid  appearances 
which  present  themselves  in  this  locality  are  those  indicating  in- 


DISEASES   OF   THE   MOUTH   AND   PHARYNX.  301 

flammatory  and  ulcerative  action:  the  redness  and  swelling  occur 
under  two  very  distinct  forms — the  acute  and  the  chronic. 

a.  With  some  febrile  disturbance,  which  rarely  runs  very  high, 
we  have  general  redness  and  swelling  of  all  the  adjacent  structures; 
sometimes  involving  the  root  of  the  tongue,  and  not  unfrequently 
the  submaxillary  region,  accompanied  by  great  difficulty  of  swal- 
lowing, especially  when  liquids  are  taken,  nothing  perhaps  causing 
greater  pain  than  the  patient's  own  saliva,  which  for  this  reason  he 
commonly  spits  out ;  the  tongue  is  much  coated,  and  acquires  after 
a  time  a  sodden  buff-leather  aspect.  When  we  can  get  a  view  of 
the  throat,  its  aperture  seems  encroached  on  from  all  sides,  and  the 
uvula  is  long  and  large ;  the  mucous  membrane  is  remarkably  red 
and  injected.  These  circumstances  are  quite  sufficient  to  charac- 
terize quinsy:  its  course  is  usually  rapid,  ending  in  a  few  days  by 
suppuration,  and  occasionally  by  resolution.  The  liability  to  its  re- 
currence is  so  great,  that  any  history  of  a  similar  attack  is  of  value 
in  considering  the  probable  termination  of  sore  throat  in  any  given 
case. 

The  occurrence  of  sore  throat  is  so  common,  while  in  certain  circumstances  it 
is  an  indication  of  such  importance,  that  a  few  words  must  be  said  on  its  general 
bearings  as  a  symptom  of  disease.  In  its  simplest  form,  as  a  result  of  exposure 
to  cold,  it  is  the  same  affection  which  in  one  portion  of  the  mucous  membrane 
causes  coryza,  in  another  catarrh:  in  the  pharynx  slight  redness  is  seen  on  inspec- 
tion, very  little  difficulty  in  swallowing  is  experienced,  and  the  feeling  of  soreness 
soon  subsides :  there  is  from  the  first  very  little  fever,  and  its  severity  is  rather  pro- 
portioned to  the  catarrhal  symptoms  than  to  those  of  sore  throat.  A  very  differ- 
ent state  of  things  exists  when,  instead  of  general  irritation  of  the  mucous  mem- 
brane, inflammation  attacks  the  larynx ;  the  soreness  of  throat  and  difficulty  of 
swallowing  are  very  much  more  pronounced,  pyrexia  is  distinct,  and  yet  on  in- 
spectign  little  redness  is  seen,  and  that  redness  has  a  livid  aspect.  In  scarlatina, 
again,  the  fever  generally  runs  high ;  but  the  cause  of  the  soreness  is  at  once  dis- 
covered on  inspection,  in  very  extensive  redness,  spots  of  an  aphthous  or  ulcerated 
appearance,  or  even  sloughing ;  in  milder  cases  its  true  character  is  exhibited  by 
the  appearance  of  the  cutaneous  eruption ;  in  severer  cases,  the  existence  of  an 
epidemic  coupled  with  the  occurrence  of  intense  fever,  considerable  prostration, 
great  lividity  of  the  throat  and  ulceration,  without  much  swelling,  enable  us  to 
assign  to  them  their  true  character  even  when  redness  of  skin  does  not  exist,  or 
has  receded. 

From  all  of  these  quinsy  is  distinguished  by  its  local  nature,  by  the  swelling 
which  goes  along  with  it,  and  by  the  fever  being  only  in  proportion  to  the  local 
action  going  on.  And  although  the  name  be  commonly  restricted  to  those  cases 
in  which  matter  forms,  all  are  to  be  regarded  as  belonging  to  the  same  class,  which 
present  such  symptoms,  even  if  the  inflammation  end  without  suppuration. 

I.  In  the  chronic  form  the  same  strictures  may  be  implicated  in 
a  less  degree,  a  generally  dusky  redness  prevailing  with  no  great 
amount  of  swelling;  or  there  may  be  chronic  enlargement  of  the 
tonsils  only,  or  a  permanently  elongated  condition  of  the  uvula, 
which  are  both  by  no  means  uncommon  as  sequelae  of  acute  attacks. 
Not  only  do  these  appearances  differ  greatly  from  those  presented 
by  quinsy,  but  the  history  is  also  totally  dissimilar:  if  there  have 
been  some  aggravation  of  the  symptoms  within  a  few  days,  to  which 
the  attention  of  the  patient  is  especially  directed,  still  the  evidence 


302  DISEASES    OF   TIIE    MOUTn    AND    PHARYNX. 

of  old  standing  disease  is  not  wanting  if  the  case  have  been  pro- 
perly investigated. 

It  can  scarcely  be  necessary  to  add  a  caution  against  being  deceived  by  the  ab- 
sence of  any  appearance  of  active  congestion,  into  the  belief  thai  the  sure  throat 
•is  of  old  standing  and  of  small  moment,  when  fever  is  present:  such  an  error 
would  show  entire  ignorance  of  all  right  principles  of  diagnosis.  Enlarged  tonsils 
are  very  often  the  effect  of  the  scrofulous  taint,  and  occur  in  early  life:  symptoms 
of  cough  and  dyspnoea,  by  which  attention  is  first  called  to  the  case,  may  lead  to 
a  suspmion,  of  phthisis,  from  the  want  of  evidence  of  any  other  affection  by  which 
they  might  be  accounted  for,  till  an  inspection  of  the  throat  at  once  explains  the 
mystery?  An  elongated  uvula  is  similarly  a  cause  of  cough;  and  both  may  tend 
to  excite  and  keep  up  bronchial  irritation  to  an  unusual  extent. 

The  observant  practitioner  will  in  all  such  cases  notice  peculiarities  which  serve 
to  call  his  attention  to  the  throat;  thickness  of  speech,  liability  to  sore  throat,«pc- 
casional  difficulty  in  deglutition,  even  when  pain  is  not  spoken  of,  such  as  fluids 
returning  by  the  nose  sometimes;  deafness,  and  especially  the  sound  of  the  cough 
which  may  be  described  as  a  throat-cough:  but  whenever  the  symptoms  are  not 
fully  explained  by  the  stethoscope,  an  inspection  of  the  throat  is  a  wise  precau- 
tionary measure  before  pronouncing  a  diagnosis. 

e.  Ulceration  of  the  fauces  occurs  in  three  distinct  forms:  (1)  As 
the  residue  of  an  acute  attack ;  (2)  as  a  primary  disorder  in  scro- 
fulous and  cachectic  states ;  (3)  as  a  consequence  of  syphilitic  poi- 
soning. After  quinsy  the  ulcer  is  generally  pretty  far  forward, 
after  scarlatina  the  tonsil  is  the  usual  site  of  ulceration ;  the  scrofu- 
lous ulcer  is  very  often  in  the  velum,  the  syphilitic  usually  reaches 
towards  the  back  of  the  pharynx.  That  resulting  from  an  acute 
attack  is  generally  superficial ;  the  scrofulous  is  deep,  but  has  flabby, 
perhaps  jagged  edges,  which  do  not  project;  it  often  exists  as  a 
complete  perforation  of  the  velum:  the  syphilitic,  again,  is  deep  and 
rounded,  with  elevated  serpiginous  and  defined  borders. 

So  far  as  diagnosis  is  concerned,  these  conditions  might  be  accurately  deter- 
mined by  a  correct  history.  In  regard  to  treatment,  the  division  of  most  import- 
ance is  into  the  syphilitic  and  non-syphilitic  ulceration.  Both  the  other  forms  are, 
in  great  measure,  constitutional,  and  must  be  met  rather  by  such  remedies  as  are 
suited  to  the  general  condition  of  the  patient,  than  by  those  which  have  merely  a 
local  effect.  In  the  female  sex  there  is  both  greater  difficulty  in  making  out  the 
previous  existence  of  primary  syphilis,  and  greater  unwillingness  to  confess  that 
such  may  have  been  its  cause,  than  in  males ;  to  say  nothing  of  the  reluctance  felt 
by  the  medical  man  in  even  hinting  such  a  possibility.  AVhen  the  ulcer  is  rounded 
and  excavated,  with  elevated  margins,  we  must  endeavour,  by  seeking  in  other  di- 
rections for  evidence  of  syphilitic'poisoning,  to  obtain  some  indication  that  may 
aid  in  solving  the  doubt  which  such  a  condition  will  naturally  raise  in  the  mind. 

True  aphthae  are  less  common  on  the  fauces  than  on  the  tongue 
and  lips;  but  a  somewhat  analogous  formation  is  frequently  ob- 
served there,  which  may  be  either  a  true  exudative  process,  or 
merely  the  inspissated  secretion  of  some  of  the  follicles.  These 
spots  may  be  mistaken  for  ulceration,  and  it  is  only  necessary  to 
warn  the  student  of  this  possibility ;  though,  probably,  the  mistake 
is  not  a  very  important  one.  When  there  is  distinctly  a  deposit 
upon  the  surface,  its  significance  is  somewhat  different  from  that  of 
aphthae  on  the  tongue ;  it  is  only  in  childhood  that  its  presence  is 
of  importance,  because  in  them  it  sometimes  exists  to  a  great  extent: 


DISEASES   OF   THE  MOUTH   AND   PHARYNX.  303 

the  disease  is  known  as  diphtheritis,  and  indicates  a  constitutional 
tendency  to  that  form  of  plastic  exudation  which  is  of  so  much  mo- 
ment when  it  invades  the  trachea  in  croup. 

§  3.  The  Glandular  Structures. — The  inflammation  of  the  fauces 
sometimes  extends  to  the  submaxillary  region,  and  subsequently 
excites  inflammation  of  the  salivary  glands:  but  these  glands  are 
also  liable  to  be  primarily  affected.  The  swelling,  though  accom- 
panied with  difficulty  in  swallowing,  is  chiefly  external:  the  parotid, 
as  the  largest  gland,  gives  the  principal  feature  to  the  disease,  which 
has  hence  been  called  parotitis — better  known  by  its  familiar  epi- 
thet, "mumps."  It  is  chiefly  a  disease  of  childhood  and  youth,  and 
is  not  characterized  by  much  febrile  disturbance:  it  is  of  impor- 
tance as  causing  the  disfiguring  abscesses  which  are  apt  to  occur 
under  the  jaw  in  scrofulous  subjects,  when  the  surrounding  textures 
become  involved  in  the  inflammation  which  primarily  attacks  the 
salivary  glands.  This  disorder  furnishes  us  with  the  most  marked 
examples  of  metastasis;  the  testicle  and  the  mamma  being  each 
liable  to  inflammation  during  its  continuance. 

Chronic  enlargements  of  the  cervical  glands  occur  from  a  variety 
of  causes  in  scrofulous  constitutions;  and  these  are  ever  apt,  on 
the  occasion  of  any  little  excitement  or  inflammatory  action,  to  ter- 
minate in  abscess.  In  almost  every  case  of  suppurative  cutaneous 
affection  of  the  face  or  scalp,  they  exist  in  greater  or  less  degree ; 
but  when  the  individual  is  free  from  constitutional  taint,  they  are 
of  no  importance;  the  cause  being  removed,  the  effect  of  neces- 
sity ceases  in  a  healthy  person. 


304 


CHAPTER  XXV. 

t 

EXAMINATION  OF  TIIE  ABDOMEN. 

History  of  Abdominal  Disease — General  Symptoms — Effects  upon 
the  Health — Sensations  often  referred  to  other  Regions — Actual 
Examination — of  Outlets — of  Excreta — of  Abdomen  itself — by 
Inspection — by  Palpation — by  Percussion. 

Before  entering  upon  the  consideration  of  the  various  organs 
contained  in  the  abdomen,  and  their  special  maladies,  it  may  be 
well  to  advert  to  a  few  general  facts  connected  with  the  diagnosis 
of  diseases  of  nutrition.  Regarding  the  brain  as  the  centre  of  in- 
nervation, the  thorax  as  that  of  the  circulation,  the  abdomen  is 
especially  the  region  in  which  the  processes  of  assimilation  and  ex- 
cretion are  performed.  It  is  not  meant  that  this  definition  is  abso- 
lutely accurate;  but,  as  an  approximation  to  the  truth,  it  points 
out  in  what  direction  we  are  to  look  for  the  signs  and  symptoms  of 
disease  there,  as  connected  with  the  ingestion  of  food,  the  pre- 
paration of  proper  elements  for  absorption,  their  transmission  into 
the  circulation,  the  rejection  of  useless  materials,  and  the  removal 
of  waste  or  effete  particles,  as  well  as  the  necessity  for  the  perfect 
integrity  of  the  organs  by  which  these  processes  are  carried  on. 
That  the  deviations  from  healthy  action  should  manifest  themselves 
in  altered  condition  of  blood,  in  imperfect  nourishment  of  tissues, 
and  in  functional  disturbance  of  distant  organs,  to  which  the  blood 
is  carried,  can  cause  no  surprise;  and  the  difficulties  of  the  diag- 
nosis are  only  that  while,  on  the  one  hand,  the  deteriorated  condition 
of  the  blood  may  not  be  simply  due  to  defective  assimilation  and 
excretion  by  abdominal  viscera ;  on  the  other,  important  changes  in 
the  circulation  and  innervation  must  react  upon  the  abdominal 
organs,  as  it  is  by  these  two  great  physiological  functions  that  their 
integrity  and  power  are  supplied  and  sustained. 

With  reference  to  history,  we  must  admit  that  it  is  often  not  re- 
liable, nor  perhaps  very  material:  no  one  entirely  escapes  occa- 
sional derangement  of  stomach  and  bowels,  and  it  is  impossible  to 
say  where  healthy  reaction  against  improper  food  ceases,  and  un- 
healthy action  begins;  hence,  in  chronic  diseases,  there  are  always 
a  number  of  antecedent  phenomena,  and  it  requires  skill  to  select 
those  which  are  really  valuable  as  facts  in  the  history,  and  greater 
impartiality  than  is  possessed  by  most  medical  men,  to  avoid  putting 
the  necessary  questions  in  such  a  form  as  to  elicit  the  answers  which 
we  expect  to  receive,  from  the  general  tenor  of  the  symptoms.  In 
cases  of  acute  disease  there  is  less  difficulty  in  obtaining  correct 
information  regarding  the  sensations  and  experiences  of  the  patient 


EXAMINATION   OP    THE    ABDOMEN.  305 

since  the  severe  symptoms  arose;  but  here  again  we  are  encountered 
by  the  difficulties  that  the  sensations  in  the  abdomen  are,  at  no  time, 
very  defined,  and  that  some  prior  illness,  the  historical  evidence  of 
which  is  very  defective,  may  have  very  considerably  altered  the 
organic  constitution  or  functional  power  of  the  viscus. 

The  totality  of  the  general  symptoms  marking  inflammatory  fever 
has  the  same  value  here  as  in  other  acute  attacks:  sometimes  we 
derive  secondary  aids  to  diagnosis  from  the  skin  having  a  feeling  of 
remarkable  dryness,  the  pulse  being  small  and  wiry,  or  intermit- 
ting, &c. :  the  tongue  always  presents  an  unnatural  appearance  in 
derangements  of  digestion,  and  the  bowels  are  seldom  regular  in 
their  action,  or  the  feces  healthy  in  character;  besides  this,  we  find 
changes  in  the  appetite,  in  the  character  of  the  urine,  &c.  Each 
of  these  symptoms  has  therefore  a  twofold  meaning;  first,  as  it 
forms  one  of  a  group  which  proves  whether  the  attack  be  acute  and 
inflammatory,  or  chronic ;  second,  as  it  stands  for  one  of  the  signs 
of  disorder  in  the  particular  organ;  it  is  very  important  to  bear  in 
mind  this  double  application,  and  to  consider  how  far  each  is  to  be 
taken  as  evidence  of  the  general  condition  which  the  whole  group 
tends  to  prove,  or  derives  its  importance  from  mere  local  circum- 
stances ;  e.  g.,  how  far  a  coated  tongue  is  to  be  taken  as  evidence  of 
inflammatory  action  or  of  disordered  bowels. 

With  reference  to  the  appearance  of  the  patient:  any  degree  of 
emaciation  points  out  a  possible  defect  in  assimilation ;  even  if  it 
amount  to  no  more  than  that  the  usual  degree  of  obesity  observed 
at  advancing  periods  of  life  is  absent,  we  may  still  be  not  far  wrong 
in  assuming  that  the  individual  is  the  subject  of  weak  or  faulty  di- 
gestion; but  extreme  emaciation  is  a  very  constant  consequence  of 
severe  abdominal  disease.  The  aspect  of  the  face  and  the  colour 
of  the  skin  are  each  of  them,  again,  valuable  sources  of  informa- 
tion in  specific  forms  of  disease. 

The  sensations  are  not  confined  to  the  abdomen:  very  many  of 
the  functional  disturbances  of  the  brain  (see  Chap.  XIII.)  are  only 
to  be  accounted  for  as  results  of  irregularity  in  the  digestive  pro- 
cesses; dyspnoea  and  palpitation,  pains  in  the  sternum  or  between 
the  shoulders,  that  pain  in  the  right  shoulder  stated  to  be  sympa- 
thetic of  disease  of  the  liver  especially,  are  all  of  them  attributable 
in  like  manner  to  abdominal  disturbance.  In  the  abdomen  itself 
uneasy  sensations  are  produced  by  unusual  enlargements  of  organs, 
by  increased  irritability  in  congestive  states,  and  by  irritating 
properties  of  the  contents  of  the  hollow  viscera;  as  also  by  any 
'unusual  character  of  the  secretions  which  prevents  the  normal 
changes,  or  excites  others  which  are  abnormal,  or  renders  them  un- 
suited  to  the  membrane  which  they  traverse  in  their  passage. 

As  we  proceed  with  the  inquiry  we  shall  find  many  of  the  symp- 
toms thus  cursorily  alluded  to  come  more  distinctly  forward  as  evi- 
dence of  disease  of  the  various  organs  contained  in  the  abdomen ; 
20 


306  EXAMINATION    OF  THE    ABDOMEN. 

but  we  must  first  consider  what  aid  may  be  derived  from  the  appli- 
cation of  physical  investigation  to  diagnosis. 

First,  we  obtain  very  certain  information  from  the  exploration  of 
tho  outlets,  the  mouth,  the  rectum  and  the  vagina;  but  with  the 
exception  of  that  derived  from  the  state  of  the  tongue,  the  extent 
of  its  application  is  extremely  local  and  limited. 

Secondly,  the  excretions,  by  their  changes  in  appearance  and 
characters,  afford  very  valuable  instruction.  The  aid  of  chemical 
analysis  has  been  brought  to  bear  very  fully  on  the  condition  of 
the  urine,  and  in  fact  our  whole  knowledge  of  diseases  of  the  kid- 
ney may  be  said  to  rest  upon  the  chemistry  of  the  secretion;  but 
the  same  progress  has  not  yet  been  made  in  regard  to  the  feculent 
discharges,  and  any  knowledge  that  has  been  gained  is  inapplicable 
for  the  purpose  of  diagnosis. 

Thirdly,  the  most  valuable  physical  signs  are  derived  from  (a) 
inspection,  (b)  palpation,  (c)  percussion,  on  each  of  which  a  few 
words  must  be  said.  Auscultation  is  rarely  applicable:  in  health 
no  regular  sounds  are  heard,  which  by  their  irregularity  might  in- 
dicate disease ;  its  employment  in  abdominal  aneurism  we  have 
already  noticed,  and  it  is  also  useful  in  detecting  the  placental 
bruit,  and  the  pulsations  of  the  foetal  heart  in  pregnancy. 

a.  Inspection  indicates  deviations  from  the  natural  contour  pro- 
duced by  general  fulness  or  local  enlargements,  serving  both  to 
suggest  and  to  correct  other  modes  of  investigation. 

We  observe  a  uniform  and  equable  distention  in  peritonitis,  which  contrasts 
alike  with  the  shrunken  and  retracted  condition  sometimes  seen  in  colic  and  during 
the  pain  accompanying  the  passage  of  gall-stones,  and  with  the  irregular  forms  of 
distention  of  an  analogous  kind  which  are  noticed  in  enteritis  and  obstruction. 
Similarly  the  simple  inspection  of  the  abdomen  points  out  in  many  cases  a  very 
marked  difference  between  the  distended  peritoneal  sac  of  ascites  pushing  out  the 
ribs  as  well  as  the  abdomen,  and  the  prominent  rounded  belly  of  ovarian  dropsy, 
which  very  frequently  evidently  projects  more  on  one  side  than  the  other.  No 
less  different  is  the  aspect  of  general  fulness  in  pregnancy  from  local  swelling  in 
disease.  In  the  epigastrium  the  outline  of  a  full  stomach,  and  still  more  of  an 
enlarged  one,  may  be  distinctly  defined,  and  thus  afford  valuable  assistance  in  the 
diagnosis  of  its  actual  condition.  The  uplifted  ribs  on  the  right  side  by  enlarged 
liver,  on  the  left  by  enlarged  spleen,  each  point  out  the  direction  in  which  inves- 
tigation ought  to  proceed. 

b.  As  a  necessary  adjunct  to  inspection,  and  as  a  means  of  ascer- 
taining the  cause  of  any  deviation  in  form,  palpation  affords  more 
information  than  any  other  means  of  exploring  the  abdominal 
cavity.  It  often  indeed  serves  to  detect  deviations  from  health, 
which  would  otherwise  escape  observation  altogether;  and  very 
many  of  the  more  important  characters  of  disease  in  the  abdominal 
viscera  depend  on  its  correct  application.  It  embraces  the  sense 
of  resistance  or  immobility  of  parts,  their  hardness  and  tenderness, 
and  their  relative  size;  it  determines  the  value  of  pulsation;  it  in- 
dicates fluctuation. 

We  might  here  go  over  almost  all  the  important  diseases  of  the  abdomen,  and 
point  out  the  various  lessons  which  palpation  teaches;  but  they  are  so  important, 


EXAMINATION   OF    THE   ABDOMEN.  307 

that  they  must  be  again  mentioned  in  each  particular  case,  and  the  reader  is  re- 
ferred to  the  section  on  morbid  growths  (Chap.  IX.,  Div.  II.,  §  2)  for  the  details 
of  the  evidence  which  it  affords  in  the  varieties  of  abdominal  tumour.  In  making 
the  examination,  the  student  has  to  consider  whether  what  is  felt  as  a  deviation 
from  natural  form,  consist  simply  of  enlargement  of  parts,  or  be  absolutely  a  new 
growth  in  so  far  as  this  is  indicated  by  outline;  next  its  form,  whether  smooth  and 
rounded,  or  nodulated  and  irregular;  and  then  its  attachments,  natural  and  ac- 
quired. 

c.  Percussion  may  be  said  to  be  almost  essential  to  a  correct  ap- 
preciation of  the  results  of  both  the  preceding  sets  of  observations. 
It  gives  us  the  very  valuable  information  whether  any  visible  altera- 
tion in  form  be  wholly  caused  by  the  presence  of  solid  or  fluid 
matter,  or  chiefly  by  the  presence  of  the  gaseous  contents  of  the 
intestine;  while  the  degree  of  dulness  heard  on  percussion  where  a 
tumour  is  felt,  determines  to  a  certain  extent  its  depth  and  thick- 
ness: it  is  still  more  useful  in  tracing  out  the  origin  and  connexion 
of  tumours  when  distention^prevents  our  being  able  to  reach  their 
attachments  with  the  finger,  or  where  they  take  their  rise  under 
the  solid  covering  of  the  ribs.  It  is  no  less  important  as  it  aids  in 
mapping  out  the  extent  and  form  of  organs  and  tumours,  as,  for 
example,  the  shrunken  liver,  the  enlarged  uterus,  or  the  distended 
bladder. 

When  considered  in  detail,  there  is  no  question  of  diagnosis  which  the  percus- 
sion of  the  abdomen  tends  so  much  to  elucidate  as  that  of  ascites  and  ovarian 
dropsy.  (See  Chap.  XXXII.)  Remarkable  resonance  forms  the  chief  charac- 
teristic of  tympanites.  The  absence  of  dulness  on  percussion  serves  to  discrimi- 
nate cases  of  chronic  peritonitis  without  fluid,  from  those  in  which  ascites  is  pre- 
sent; but  the  student  must  be  reminded  that  when  the  patient  is  upon  his  back,  a 
considerable  amount  of  fluid  may  accumulate  in  the  lower  and  posterior  parts  of 
the  cavity,  without  manifestly  altering  the  resonance  on  percussion. 


308 


CHAPTER  XXVI. 

DISEASES    OF   THE    (ESOPHAGUS   AND    STOMACH. 

Uncertainty  of  Symptoms — Sympathetic  Affections  of  other  Organs 
— Diagnosis  a  Process  of  Exclusion — §  1,  The  (Esophagus  and 
Cardiac  End  of  the  Stomach — §  2,  Organic  Lesions  of  the  Sto- 
mach— Stricture  of  Pylorus — Ulceration — Gastritis  — Dilata- 
tion— §  3,  Functional  Disorders  of  the  Stomach — Irritability — 
Distention — Faulty  Secretion — Associations  of  Dyspepsia. 

No  longer  guided  by  the  objective  phenomena  which  serve  for 
such  clear  indications  in  the  affections,  of  the  mouth  and  pharynx, 
we  now  come  to  a  class  of  diseases  which  for  their  complete  inves- 
tigation require,  more  than  all  other  perhaps,  the  exercise  of  sound 
judgment  and  careful  discrimination.  Making  up,  as  they  do,  the 
largest  portion  of  the  sum  of  minor  ailments  which  medicine  is 
called  on  to  remedy,  individually,  their  importance,  with  one  or  two 
exceptions,  is  not  great;  and  consequently  the  opportunity  of  stu- 
dying them  in  hospital  practice  is  but  small,  while  that  little  is  too 
often  neglected,  from  the  necessity  the  student  feels  of  giving  his 
short  period  of  study  to  the  graver  or  more  acute  diseases  pre- 
sented to  him. 

The  common  disorders  of  the  digestive  canal  may  be  said  to  be 
but  three,  dyspepsia,  constipation,  diarrhoea.  And  yet  in  each  of 
these  conditions  how  much  remains  behind — how  much  to  guide  our 
practice,  if  we  but  knew  it — how  much  that  is  as  yet  obscure,  if  not 
quite  inexplicable! 

It  is  quite  beyond  the  scope  of  our  present  plan  to  enter  into 
all  the  details  connected  with  so  complex  a  subject  as  dyspepsia;  it 
must  suffice  to  point  out  the  leading  features  by  which  symptoms 
may  be  referred  to  the  stomach,  and  the  general  characters  by 
means  of  which  one  form  may  be  discriminated  from  another,  and  so 
that  class  of  remedies  be  selected  which  may  reasonably  be  deemed 
most  suitable.  It  will  probably  be  advantageous  to  consider  the 
more  severe  diseases  before  inquiring  into  those  which  .are  less  im- 
portant. 

Much  of  the  uncertainty  that  attends  our  knowledge  of  disorders  of  the  stomach 
is  caused  by  the  necessity  of  relying  so  much  on  the  sensations  of  the  patient, 
since  in  many  cases  no  anatomical  lesions  have  been  clearly  associated  with  the 
symptoms  detailed.  The  practitioner  is  consequently  obliged  to  theorize  as  best 
he  may  on  the  h  priori  effects  which  he  would  expect  from  faulty  secretion,  de- 
ficient muscular  action,  and  nervous  irritability,  to  contrast  these  inferences  with 
sensations,  the  real  import  of  which  he  can  only  guess  at,  because  the  descriptions 
of  the  patient  are  generally  so  faulty,  that  in  asking  questions  he  often  suggests  the 
very  answers  he  receives.     A  dyspeptic  physician  is  very  likely  thus  to  mislead 


DISEASES    OF    THE    (ESOPHAGUS   AND    STOMACH.       309 

both  himself  and  his  patient,  by  rendering  their  sensations  into  the  language  of 
his  own  ailments. 

The  information  we  derive  is  obtained  from  three  distinct  sources,  the  sympa- 
thetic affections  of  the  head  and  those  of  the  chest,  and  the  symptoms  more  di- 
rectly obtained  from  the  stomach  and  abdomen.  In  the  head,  pain,  vertigo,  par- 
tial blindness,  temporary  derangement  of  function,  &c.  In  the  chest,  cough,  and 
especially  palpitation,  local  pain,  &c.  For  the  grounds  of  distinction,  by  which 
these  functional  disturbances  may  be  recognised,  reference  must  be  made  to  the 
chapters  on  the  diseases  of  those  organs;  here  suffice  it  to  say  that  the  symptom 
generally  stands  alone;  there  is  no  other  traceable  to  the  same  region,  such  as 
there  certainly  would  be  were  the  single  symptom  a  sign  of  disease  there;  more  es- 
pecially, it  is  transient,  and  generally  of  frequent  recurrence,  so  that  a  patient  per- 
haps complains  of  palpitation,  when  heart  and  pulse  are  alike  quiet  and  normal 
at  the  time  of  examination,  to  be  again  excited  by  the  same  sympathy  which  had 
previously  caused  it. 

But,  in  addition,  some  other  symptom,  or  rather  train  of  symptoms,  will  be 
found  in  connexion  with  the  stomach;  loss  of  appetite  or  vomiting,  sense  of  weight, 
distention  or  pain,  either  referred  directly  to  the  stomach  or  distinctly  aggravated 
by  the  opposite  states  of  either  fasting  or  repletion,  combined  generally  with  ir- 
regularity of  the  bowels,  constipation,  or  relaxation,  or  an  alternation  of  both  con- 
ditions. The  seat  of  the  pain  or  uneasiness  varies  a  little  within  certain  limits; 
but  there  will  generally  be  no  difficulty  in  assigning  it  to  its  proper  source,  by  in- 
vestigating the  conditions  and  signs  of  disease  in  adjoining  organs,  which  might 
by  possibility  give  rise  to  similar  symptoms.  f 

In  dyspepsia,  as  in  hysteria,  when  the  pathology  of  the  distur- 
bance is  so  little  understood,  the  only  safe  principle  of  diagnosis  is 
that  of  exclusion.  The  possible  conditions  of  the  brain,  of  the 
lungs,  and  of  the  heart  must  be  duly  weighed,  and  attention  must 
also  be  paid  to  the  condition  of  other  abdominal  viscera. 

§  1.  The  (Esophagus  presents  only  one  form  of  disease, — a  cer- 
tain degree  of  closure  either  from  stricture  or  from  spasm.  The 
complaint  of  the  patient  is  of  difficulty  in  swallowing,  a  sensation 
of  the  food  stopping  somewhere  in  its  course,  and  its  being,  again 
brought  up.  The  distinctive  feature  of  this  state  is,  that  the  re- 
turn of  the  food  is  immediate ;  very  few  mouthfuls  can  be  swallowed, 
perhaps  no  more  than  one  before  the  pain  and  discomfort  become 
such  that  the  patient  cannot  proceed  till  that  has  been  rejected; 
and  the  difficulty  is  always  proportioned  to  the  solidity  of  the  food, 
fluids  continuing  to  pass  when  no  solid  matter  is  received  into  the 
stomach  at  all.  The  rejected  matter  is  simply  masticated  food,  and 
has  no  smell  of  acidity,  nor  does  the  patient  perceive  any  taste  of 
bile. 

True  stricture  comes  on  very  gradually  and  insidiously,  is  ac- 
companied by  marked  emaciation,  and  generally  attended  with  a 
sense  of  hunger  which  cannot  be  relieved  in  consequence  of  the 
impossibility  of  filling  the  stomach  with  food:  if  necessary,  the 
diagnosis  may  be  made  still  more  clear  by  introducing  the  probang. 
The  closure  from  spasm  is  generally  more  suddenly  developed,  and 
is  not  attended  by  the  same  constitutional  effects.  In  stricture  the 
condition  is  permanent,  and  the  only  perceptible  difference  in  the 
power  of  swallowing  is  due  to  the  quality  of  the  food;  in  spasm 


310        DISEASES    OF    THE    (ESOPHAGUS   AND   STOMACH. 

the  difficulty  varies  in  consequence  of  circumstances  for  the  most 
part  inappreciable.  The  remote  cause  of  spasm  would  appear 
Sometimes  to  be  mere  nervous  irritability;  in  other  cases  it  is  clue 
to  local  irritation  of  some  portion  of  the  mucous  membrane,  or  to 
the  pressure  of  a  tumour  on  the  oesophagus.  In  spasmodic  stric- 
ture the  probang  can  be  passed,  although  it  meets  with  some  resist- 
ance, when  any  local  cause  of  irritation  exists.  The  circumstances 
here  referred  to  apply  equally  to  disease  of  the  cardiac  opening  of 
the  stomach,  which  produces  an  exactly  analogous  effect  in  regard 
to  the  introduction  of  food,  as  that  of  closure  of  the  oesophagus, 
and  therefore  need  not  be  considered  separately. 

In  seeking  for  characters  by  which  these  diseases  may  be  distinguished,  we  ob- 
serve that  any  evidence  of  "exaltation"  or  of  nervous  irritability  in  other  organs. 
prepares  us  for  the  existence  of  a  similar  condition  in  the  oesophagus :  if  we  learn 
that  any  thing  liable  to  irritate  the  membrane  has  been  swallowed,  or  if  we  find  any 
redness  or  spots  of  ulceration  on  the  fauces,  we  suspect  the  coexistence  of  spasm 
with  local  irritation:  if  a  tumour  exist,  we  should  have  concomitant  evidence  of 
pressure  on  the  trachea. 

It  further  deserves  notice,  that  occasionally  ulceration  of  the  epiglottis  and  im- 
perfect closure  of  the  entrance  of  the  windpipe  excite  coughing,  so  immediately 
upon  the  act  of  swallowing,  that  great  part  of  each  mouthful  is  returned  before  it 
can  pass  the  irritable  spot.  Here  there  is  not  necessarily  any  spasm  of  the  oeso- 
phagus; and,  if  along  with  the  known  existence  of  cough,  and  probably  also  of 
hoarseness  or  raucous  breathing,  the  act  of  deglutition  be  watched,  its  cause  will 
be  at  once  revealed. 

§  2.  Organic  Diseases  of  the  Stomach. — The  two  most  important 
lesions  found  in  the  stomach  are  stricture  of  the  pylorus,  which  is 
very  often  cancerous,  and  simple  ulceration  of  the  mucous  mem- 
brane. Gastritis  is  a  disease  of  very  rare  occurrence  in  its  acute 
form ;  dilatation  is  most  commonly  the  result  of  partial  closure  of 
the  pylorus,  but  possibly  also  commences  as  an  idiopathic  disorder. 

a.  'Stricture  of  the  Pylorus,  in  its  earlier  stage,  cannot  be  dis- 
tinguished from  mere  functional  derangement;  and  when,  as  very 
commonly  happens,  dyspepsia  is  conjoined  with  it,  the  patient  may 
appear  to  recover  under  treatment  while  yet  the  disease  proceeds 
unchecked.     The  most  constant  symptom  of  stricture  of  the  pylo- 
rus is  vomiting:  but  I  have  seen  the  disease  run  on  to  a  fatal  ter- 
mination, in  which,  during  a  long  period,  that  symptom  was  absent 
in  consequence  of  an  ulcerated  opening  communicating  with  the 
duodenum.     When  accompanied  by  ulceration,  there  is  usually,  at 
some  period  or  other,  grumous  vomiting,  which  owes  its  appearance 
to  a  small  quantity  of  blood,  altered  by  the  secretion  of  the  sto- 
mach; sometimes  there  is  more  copious  hemorrhage.    The  stomach 
may  become    enormously   distended:    indeed    dilatation    probably 
always  exists,  more  or  less;  but  it  is  much  greater  in  simple  thick- 
ening than  in  scirrhus  of  the  pylorus,  when  the  stomach  is  more 
irritable,  and  its  contents  more  speedily  rejected.     Several  meals, 
or  even  the  food  of  three  or  four  days,  may  be,  in  great  part,  ac- 
cumulated before  it  is  rejected,  or,  on  the  other  hand,  the  vomiting 


ORGANIC    DISEASES    OF    THE    STOMACH.  311 

may  occur  after  every  meal:  the  longer  interval  proves  the  exist- 
ence of  dilatation,  if  any  thing  like  the  whole  quantity  of  food 
be  rejected;  the  constant  recurrence  of  the  vomiting  after  food 
shows  that  there  is  a  condition  of  irritability.  The  absence  of 
signs  of  dilatation,  when  the  vomiting  occurs  at  longer  intervals, 
and  the  return  of  the  food  after  every  meal,  are  each  of  them  more 
favourable  than  a  certain  degree  of  dilatation  with  vomiting  once 
or  twice  in  the  day,  or  at  intervals  of  two  days. 

The  progress  of  the  case  is  usually  rapid  when  the  disease  is  of 
a  malignant  character;  the  symptoms  are  unrelieved,  or  recur  with 
greater  severity;  the  aspect  of  the  patient  becomes  wan  and  sal- 
low, with  increasing  emaciation:  there  is  often  lowness  of  spirits 
and  despondency;  and  sooner  or  later,  in  most  cases,  the  presence 
of  a  hard  mass  in  the  region  of  the  epigastrium,  towards  the  right 
side,  leaves  no  doubt  of  the  presence  of  scirrhus. 

Though  analogous  in  the  fact  of  partial  closure  of  the  pylorus,  the  two  diseases 
run  a  very  different  course;  the  difference  being  caused  chiefly  by  two  circum- 
stances: the  one,  that  along  with  the  stricture  there  is  a  morbid  condition  of  the 
mucous  membrane  in  cancer,  giving  rise  to  irritability,  ulceration,  grumous  vo- 
miting, &c;  the  other,  that  when  the  disease  is  constitutional,  the  altered  condi- 
tion of  blood,  which  attends  its  progress,  necessarily  renders  it  more  rapidly  fatal 
than  mere  thickening  of  the  pylorus.  The  non-malignant  form  of  stricture  may 
be  recognised  by  its  frequent  occurrence  among  spirit  drinkers;  by  the  accom- 
panying  dilatation,  the  absence  of  hemorrhage,  the  circumstance  that  no  tumour 
can  be  felt,  and  most  especially  by  its  slow  progress:  if  the  symptoms  have  existed 
for  years,  or  even  for  many  months,  without  a  cachexia  being  established,  the  pro- 
babilities are  greatly  against  cancer. 

The  occurrence  of  hemorrhage  in  any  large  quantity  in  cancerous  disease  is  the 
exception.  At  first,  the  blood  only  appears  as  small  black  or  brownish  flakes  in 
the  vomit,  but,  at  a  later  period,  assumes  the  character  of  what  is  called  coffee- 
ground  vomiting,  the  amount  of  blood  in  which  may  be  considerable ;  distinct  he- 
morrhage is  more  probably  the  result  of  simple  ulceration.  We  look  with  great 
distrust  upon  symptoms  of  uneasiness  after  food,  eructations,  occasional  vomiting, 
and  depression  occurring  in  persons  of  temperate  habits,  unrelieved  by  treatment, 
or  progressively  getting  worse,  and  attended  with  any  degree  of  emaciation  and 
sallowness. 

It  does  not  seem  possible  generally  to  distinguish  different  forms  of  cancerous 
growth  during  life.  It  is  only  known  that  medullary  cancer  grows  much  more  ra- 
pidly; that  colloid,  even  if  present  in  the  stomach,  is  more  abundant  in  its  usual 
site,  the  mesentery;  and  that  scirrhus  is  commonly  the  most  painful  of  the  three. 
Scirrhus  is  the  most  local ;  encephaloid  and  colloid  spread  more  rapidly,  the  former 
usually  coexisting  in  the  liver ;  in  cases  in  which  scirrhus  has  spread,  it  is  also  to 
the  liver. 

While  we  are  taught  much  by  the  aspect  of  the  patient,  we  learn  little  from  the 
state  of  the  pulse,  tongue,  bowels,  &c. :  there  is  generally  constipation,  in  conse- 
quence of  the  small  quantity  of  food  which  passes  downward,  and  the  tongue  is 
often  coated  at  the  back;  the  pulse  is  for  the  most  part  weak,  but  seldom  accele- 
rated. 

b.  Ulceration. — But  little  is  known  of  this  disease  in  its  clinical 
history;  the  symptoms  seldom  present  any  degree  of  uniformity  in 
the  cases  which  have  been  watched  to  a  fatal  termination ;  they  often 
fail  to  suggest  the  idea  of  ulceration  at  all,  and  at  best  the  con- 
clusion regarding  its  existence  can  only  be  hypothetical.     Extreme 


312      DISEASES    OF    THE    (ESOPHAGUS   AND    STOMACH. 

pain  commences  immediately  after  food  is  taken,  and  before  di- 
gestion can  possibly  have  begun,  especially  if  excited  by  water  or 
bland  fluid,  a  pain  which  is  localized  in  a  particular  spot,  and  always 
recurs  at  tbe  same  place,  affords  perhaps  the  most  conclusive  indica- 
tions. Ilrcinatemesis  in  an  otherwise  healthy  individual  is  often  due 
to  the  same  cause:  but  either  may  be  wanting,  and  there  is  nothing 
to  be  recognised  beyond  ordinary  dyspeptic  symptoms.  In  some 
few7  instances  the  tongue  looks  red  and  raw,  or  spots  of  ulceration 
may  be  seen  on  it,  or  on  the  lips,  indicating  a  generally  depraved  con- 
dition of  the  mucous  membrane,  one  manifestation  of  which  may  be 
ulceration  of  the  stomach:  much  more  frequently,  however,  this  state 
of  the  mouth  is  associated  with  ulceration,  or  irritation  of  the  bowels. 

It  must  not  be  overlooked  that  simple  ulceration  of  the  stomach  is  not  a  com- 
mon pathological  state  in  the  bodies  of  persons  dying  of  other  diseases,  and  there- 
fore we  must  not  hastily  predicate  it  of  a  person  suffering  from  dyspeptic  disorder. 
Besides  the  simple  ulcer,  with  the  origin  of  which  we  are  unacquainted,  we  meet 
with  ulceration  associated  with  malignant  disease,  at  parts  distant  from  the  py- 
lorus. The  same  obscurity  of  symptoms  attends  this  as  the  other  forms  of  ulcera- 
tion, unless  grumous  vomiting  occur  to  point  more  directly  to  its  cause,  or  a  tu- 
mour be  felt  somewhere  in  the  epigastrium;  and  we  may  then  be  puzzled  to  ex- 
plain the  absence  of  obstruction.  We  also  find  destruction  of  the  mucous  mem- 
brane, and  consequent  ulceration  remaining  as  a  permanent  result  of  the  corro- 
sion and  inflammation  caused  by  irritant  poisons,  especially  the  mineral  acids  and 
alkalies.  The  history  of  recovery  from  the  acute  attack,  with  abiding  tenderness 
of  the  stomach  and  inability  to  take  food  without  great  distress,  would  point  out 
the  true  nature  of  such  a  case. 

In  speaking  of  hajmatemesis  (Chap.  VII.,  Div.  II.,  \  3,)  the  different  forms  of 
hemorrhage  were  enumerated;  and  it  may  be  here  added  that,  when  preceded  by 
local  symptoms  referrible  to  the  stomach,  that  which  occurs  early  in  life,  and  is 
abundant  and  more  florid,  is  probably  caused  by  simple  ulceration;  that  which  is 
seen  in  advanced  life,  and  is  small  in  quantity  and  grumous  in  appearance,  is  pro- 
bably connected  with  malignant  disease.  If  the  blood  have  been  brought  up  at 
some  previous  period,  and  the  symptoms  continue  stationary,  we  may  feel  consi- 
derable confidence  that  the  disease  is  not  cancerous. 

c.  Gastritis. — The  occurrence  of  idiopathic  gastritis  is  so  rare  in 
clinical  medicine  that  practically  it  need  scarcely  be  referred  to. 
It  is,  indeed,  only  known  as  the  consequence  of  the  ingestion  of  some 
irritant,  probably  of  the  nature  of  an  acrid  poison;  but  in  rare  in- 
stances it  has  followed  the  taking  a  draught  of  cold  water  when  the 
body  was  much  heated  by  exercise,  or  has  been  caused  by  indi- 
gestible food. 

Both  the  simple  ulcer  and  the  thickening  of  the  pylorus  without 
malignant  growth  have  been  referred  by  some  pathologists  to  chro- 
nic gastritis;  but  they  have  been  unable  to  point  out  any  characters 
by  which  the  gradual  changes  can  be  recognised,  before  they  have 
reached  the  points  at  which  we  have  attempted,  though  so  ineffectu- 
ally, to  make  them  subjects  of  diagnosis. 

The  symptoms  of  acute  gastritis  may  be  seen  as  part  of  more 
general  inflammation  of  the  peritoneum,  when  the  stomach  is  in- 
tolerant of  the  least  portion  of  food  or  drink;  these  again  may  be 
closely  simulated  by  sympathetic  irritation  of  the  stomach  in  in- 
flammation of  the  brain. 


FUNCTIONAL   DISORDERS.  313 

d.  Dilatation  must  be  noticed,  as  it  is  found  in  cases  in  which, 
from  the  duration  of  the  disease,  there  must  always  be  some  doubt 
as  to  the  existence  of  organic  lesion.     It  is  probably  connected, 
when  of  great  extent,  with  some  degree  of  obstruction  to  the  pylo- 
rus, but  may,  likewise,  be  a  consequence  of  habitual  distention  and 
loss  of  muscular  power.     In  its  minor  form  it  gives  rise  to  extraor- 
dinary tympanitic  resonance  over  the  whole  of  the  lower  part  of 
the  left  side  of  the  chest  as  high  as  the  axilla ;  in  its  more^ggravated 
condition  it  forms  a  sac  which  almost  fills  the  abdomen,  and  has  even 
given  rise  to  the  idea  that  the  patient  was  labouring  under  ascites. 
In  the  former  case,  the  complaint  of  pain  on  the  left  side  will  na- 
turally lead  to  percussing  the  chest;  and  the  tympanitic  sound  ex- 
tending below  the  edges  of  the  ribs,  as  well  as  above,  taken  in  con- 
junction with  the  slow  progress  of  the  ailment,  can  leave  no  doubt 
as  to  its  true  character.     In  the  latter  there  is  generally  a  history 
of  occasional  vomiting,  when  very  considerable  quantities  of  fluid 
have  been  brought  up ;  and  if  this  have  occurred  recently,  extensive 
tympanitic  resonance  will  be  observed  extending  over  the  epigas- 
trium and  left  side  generally;  if  for  some  days  there  have  been  no 
vomiting,  we  find  distinct  fulness  below  the  epigastrium,  of  a  rounded 
form,  extending  in  the  direction  of  the  umbilicus,  and  passing  thence 
towards  the  left  hypogastric  or  lumbar  region,  superficially  tympani- 
tic, but  accompanied  by  deep  fluctuation,  with  gurgling  noise  on 
movement,  which  has  been  mistaken  for  succussion. 

Latterly,  a  valuable  aid  to  diagnosis  has  been  obtained  from  the 
discovery  of  the  microscopical  sarcina  ventriculi  in  the  vomited  mat- 
ter, which  always  betrays  a  great  tendency  to  ferment.  This  ap- 
pears at  present  to  indicate  no  more  than  a  retardation  of  the  food 
in  the  stomach,  with  a  want  of  power  completely  to  empty  its  con- 
tents; and  we  are  consequently  led  to  associate  its  existence  with 
the  probability  of  a  condition  of  dilatation,  especially  that  which  ac- 
knowledges thickening  of  the  pylorus  as  its  cause. 

§  3.  Functional  Disorders  of  the  Stomach. — Dyspepsia  proper, 
accompanied  by  its  multifarious  symptoms,  can  only  be  safely  pre- 
dicated when,  after  careful  weighing  of  other  possible  states  of  sys- 
tem, we  find  a  remaining  amount  of  disturbance  which  we  have 
failed  to  account  for  in  any  other  way.  And  hence  it  is  a  rational 
conclusion  that  dyspepsia  does  coexist  with  different  states  which, 
while  sufficient  to  account  for  some  of  the  symptoms,  leave  others 
unexplained.  It  stands  in  close  relation  to  most  diseases  of  the  ab- 
dominal viscera,  either  as  their  cause  or  their  effect;  and  it  may  be 
associated  with  almost  every  chronic  ailment,  so  as  to  make  it  diffi- 
cult to  determine,  when  we  are  satisfied  of  the  coexistence,  what 
their  exact  relations  are  to  one  another.  Such,  for  example,  is  its 
combination  with  anaemia  and  hysteria;  in  both  quite  as  frequently 
the  cause  as  the  consequence  of  the  general  state;  in  both  alike  de- 
manding distinct  recognition  and  separate  treatment. 


OU      DISEASES    OF    THE    (ESOPHAGUS   AND    STOMACH. 

It  is  very  important  to  remember,  with  reference  to  the  stomach  and  its  dis- 
orders, ill  it  almost  every  patient,  no  matter  how  ignorant  or  ill-informed,  frames 
to  himself,  according  to  his  amount  of  knowledge  or  prejudice,  a  theory  of  his  ail- 
me  attribute-!  to  indigestion  all  his  sufferings,  another  constantly  alleges 
that  he  is  bilious,  a  third  is  not  satisfied  unless  he  is  well  purged,  and  a  fourth, 
who  relishes  the  pleasures  of  the  table,  is  slow  to  admit  that  his  stomach  is  over- 
taxed or  unequal  to  the  demands  made  upon  it.  No  cause  more  frequently  leads 
to  wrong  diagnosis  than  forgetting  to  separate  between  the  true  narration  of  symp- 
toms and  sensations,  which  are  our  only  guide  in  this  class  of  disorders,  and  the 
constructional'  a  theory  which  no  patient  is  able  to  form  correctly  in  his  own  case. 
Social  progress  would  stand  still  for  ever  if  nothing  were  to  pass  current  but  bare 
description;  yet,  in  the  history  of  a  case,  every  thing  else  should  be  rigidly  excluded; 
and  it  is  better  to  trace  out  the  disease  as  we  do  in  childhood,  by  our  unaided  ob- 
servation, than  to  admit  into  our  conception  the  statement  of  the  patient  that  he 
is  "bilious."  No  more  expressive  term  exists  for  a  certain  condition  of  body  than 
this;  it  is  as  true,  strictly  and  legitimately  true,  as  "fever,"  "rheumatism,"  &c: 
but  it  theorizes — it  is  a  compendious  expression  of  certaiu  symptoms;  and  it  is 
the  duty  of  the  physician,  not  of  the  patient,  to  determine  whether  this  implied 
theory  properly  expresses  the  category  of  symptoms  or  not.  In  the  present  day, 
no  ororan  is  more  hardly  deilt  with  than  the  stomach:  whether  we  consider  the 
starvation  and  improper  food  of  the  poor,  the  irregular  hours  of  the  man  of  busi- 
ness, the  pampering  and  overfeeding  of  the  rich,  or  the  still  more  pernicious  dis- 
regard of  the  proper  evacuation  of  the  effete  contents  of  the  alimentary  canal, 
which  false  delicacy,  sedentary  habits,  and  sheer  inattention  produce.  The  habits 
of  the  patient  therefore  afford  a  further  help  to  diagnosis,  as  one  of  the  elements 
in  the  history  of  the  case. 

The  symptoms  of  dyspepsia  may  be  referred  to  three  distinct 
heads — pain,  or  nervous  irritation,  impaired  muscular  action,  and 
faulty  secretion.     In  their  analysis,  it  is  to  be  remembered  that 
while  pain  is  an  evidence  of  irritability,  and  thus  perhaps  simply  of 
faulty  innervation,  it  may  also  depend  on  the  condition  of  the  mu- 
cous membrane,  and  the  character  of  its  secretion,  or  an  -over-dis- 
tention  and  spasmodic  contraction  of  the  muscular  fibre.     Similarly, 
though  distention  be  essentially  the  fault  of  the  muscular  structure, 
■which  has  become  relaxed,  weak,  and  ineffective,  yet  this  very  weak- 
ness may  be  a  symptom  of  nervous  debility,  or  may  be  simply  Caused 
by  distention  with  gas,  generated  because  the  secretion  is  imperfect. 
In  the  same  way,  faulty  secretion  may  be  directly  traceable  to  the 
condition  of  the  mucous  layer  and  follicles,  but  may  also  result  from 
imperfect  nervous  or  vascular  action,  or  follow  on  the  detention  of 
food  in  the  viscus  from  deficient  muscular  power.     Nothing,  indeed, 
can  be  more  erroneous  than  the  limitation  of  each  of  these  effects 
to  that  particular  structure  which  is  directly  concerned  in  their  pro- 
duction.    But  we  are  not  on  this  account  to  disregard  the  informa- 
tion thus  conveyed;  on  the  contrary,  pretty  nearly  all  the  complex 
cases  that  come  before  us  may  be  resolved  into  these  three  simpler 
elements — irritability,  distention,  and  faulty  secretion:   caution  is 
chiefly  to  be  exercised  in  theorizing  that  this  or  that  particular  func- 
tion is  the  one  primarily  deranged. 

a.  Irritability  presents  a  great  variety  of  phases,  which  receive 
from  patients  as  many  different  appellations.  It  is  often  manifested 
in  extreme  intolerance  of  food;  beginning  by  slow  degrees,  it  at 


FUNCTIONAL   DISORDERS.  315 

length  becomes  such  that  every  meal  is  rejected,  and  sometimes  the 
quantity  of  food  must  be  reduced  to  a  mere  spoonful,  and  its  qua- 
lity be  the  very  simplest  and  blandest  possible,  to  prevent  its  rejec- 
tion.   Such  a  form  of  irritability  may  be  produced  by  ulceration,  but 
is  certainly  not  limited  to  it.     Pain,  referred  so  often  by  the  hys- 
terical to  the  left  side,  or  described  as  passing  through  the  chest  and 
being  felt  between  the  shoulders,  or  perceived  in  the  centre  of  the 
sternum  as  well  as  over  the  epigastric  region;  a  feeling  of  emptiness 
or  craving,  which,  relieved  for  a  short  time  by  food,  returns  in  its 
full  extent  before  the  stomach  can  by  possibility  be  emptied;  sen- 
sations of  fulness,  weight,  dragging,  &c. ;  gnawing,  cutting,  tearing 
pains,  &c, — must  all  be  regarded  as  evidence  of  irritability.   It  is  ma- 
nifestly impossible  to  assign  to  all  of  these  their  true  pathological  im- 
port, or  even  to  guess  why  they  are  so  differently  described ;  but  it 
is  of  service  to  consider  their  relation  to  the  ingestion  of  food,  as 
tending  to  show  in  some  measure  their  exciting  cause.     Thus,  if  the 
disagreeable  or  painful  sensation  be  observed  shortly  after  food  is 
taken, — if  some  kinds  of  food  produce  it  at  once,  and  Others  not  at 
all,  especially  if  bland  fluids  do  not  excite  pain,  as  they  generally 
do  in  ulceration,  we  should  have  strong  reasons  for  believing  that 
the  symptom  was  chiefly  nervous,  that  the  irritability  of  the  stomach 
was  the  primary  affection.    "Whereas,  if  a  longer  interval  must  elapse 
before  the  sensation  be  aroused,  if  it  be  accompanied  by  acidity  or 
eructation,  or  if  it  exist  when  the  stomach  is  empty,  being  rather 
relieved  by  the  presence  of  food,  we  shall  probably  be  right  in  re- 
garding it  as  symptomatic  of  faulty  secretion.     If  a  sense  of  weight 
or  dragging  be  the  form  assumed,  and  it  be  experienced  at  a  still 
later  period,  we  may  assume  that  there  is  some  delay  in  the  process 
of  emptying  the  stomach,  either  as  a  consequence  of  torpidity  of 
muscle,  or  more  commonly  as  the  effect  of  over-distention :  still  more, 
if  the  pain  be  of  a  spasmodic  character,  and  very  late  in  its  occur- 
rence, it  may  be  referred  to  the  ineffective  contractions  of  the  mus- 
cular fibre  distended  beyond  its  proper  limits,  and  vainly  attempting 
to  expel  crude  and  half-digested  aliments  to  which  the  pylorus  re- 
fuses egress. 

h.  Distention. — Dilatation,  in  its  minor  and  less  important  signifi- 
cation— more  probably  distention  or  relaxation  of  muscle,  indicated 
by  the  pain  just  referred  to,  and  by  the  existence  of  unusual  reso- 
nance— is  more  likely  to  be  primary  in  persons  of  lax,  flabby,  mus- 
cular structure,  than  in  those  who  have  firm  resilient  flesh.  Such  a 
condition  is  more  probable  if  there  be  coexisting  constipation  and 
want  of  intestinal  peristaltic  action,  if  the  appetite  be  unaffected 
and  the  first  stage  of  digestion  easy;  but  it  can  scarcely  persist 
without  reacting  on  the  mucous  membrane,  through  the  delay  of 
the  food  in  the  stomach:  and  hence  it  becomes  complicated  by  evi- 
dence of  faulty  secretion.  On  the  other  hand,  one  of  the  most 
constant  effects  of  imperfect  digestion  is  the  generation  of  flatu- 


316      DISEASES    OF    THE    (ESOPHAGUS   AND   STOMACH. 

lence,  which  must  necessarily  distend  the  stomach  till  it  find  an 
outlet;  crude  and  ill-digested  food  must  also  necessarily  be  delayed 
in  passing  the  pylorus,  whether  the  muscular  action  be  at  fault  or 
not;  and  it  is  therefore  by  no  means  easy  to  say  how  much  is  due 
to  the  imperfection  of  the  muscle,  and  how  much  to  the  defect  of 
the  secretions.  More  easily  recognised  are  those  cases  in  which  the 
distention,  the  discomfort,  and  the  delay  of  the  digestive  process 
are  all  of  them  caused  by  overloading  the  stomach,  which  sooner  or 
later  rebels  against  the  habitual  overtaxing  of  its  powers.  It  may 
still  be  capable  of  disposing  readily  of  a  moderate  meal,  but  it  re- 
fuses to  propel  a  large  mass  of  heterogeneous  contents:  in  such  cases, 
probably  the  actual  overstretching  of  the  fibre  is  a  more  efficient 
cause  of  the  distention  than  the  character  or  quantity  of  the  secre- 
tion. 

c.  Faulty  Secretion. — Manifestly  combined  with  both  the  pre- 
ceding conditions,  this  cause  of  dyspepsia  is  perhaps  the  most  fre- 
quent and  tlae  most  difficult  to  manage.  It  is  related  to  various 
conditions  of  health,  acting  either  through  the  vascular  or  nervous 
system,  but  seems  to  be  also  primary  and  independent  of  them. 

(1.)  Hyperemia. — Passing  by  the  form  of  acute  gastritis,  we 
come  to  the  congestion  characterizing  a  fit  of  indigestion  brought 
on  by  excess.  Here  the  history  of  the  case,  if  correctly  given, 
leads  at  once  to  the  true  diagnosis:  the  attack  is  recent;  all  the 
symptoms  severe;  the  tongue  is  generally  foul  and  flabby;  the 
bowels  confined,  or  a  good  deal  relaxed,  but  without  febrile  symp- 
toms. A  timely  emetic,  imitating  the  relief  which  nature  some- 
times provides,  might  have  prevented  the  subsequent  congestion ; 
but  when  once  excited,  the  irritation  may  not  subside  after  the  in- 
gesta  have  passed  into  the  bowels;  vomiting  may  come  too  late,  and 
persist  even  for  days;  the  bowels,  if  unloaded  by  an  aperient,  be- 
come again  confined,  or  are  affected  with  diarrhoea.  Congestion  of 
the  liver  generally  plays  a  prominent  part  in  such  conditions;  but 
congestion  of  the  stomach  is  equally  evident  as  the  direct  effect  of  a 
debauch;  and  there  is  not  only  perverted  secretion,  but  irritability 
dependent  on  the  sort  of  erythematous  condition  of  the  mucous 
membrane  which  the  very  idea  of  congestion  implies.  Similar 
results  are,  no  doubt,  also  traceable  when  the  congestion  of  the 
stomach  is  of  that  passive  form  which,  in  its  very  marked  examples, 
is  accompanied  by  hrernatemesis,  and  is  produced  by  obstructed 
hepatic  circulation.  General  plethora  evidently  cannot  be  a  cause 
of  dyspepsia,  because  any  interference  with  the  action  of  the  sto- 
mach would  immediately  reduce  the  quantity  of  material  converted 
into  blood,  and  of  necessity  diminish  the  plethora;  but  probably  a 
fit  of  indigestion  would  be  more  severe  in  the  plethoric  individual 
than  in  another. 

(2.)  AnEemia,  on  the  other  hand,  is  unknown  as  a  local  affection, 
but,  as  a  general  condition  of  system,  evidently  exercises  great  in- 


FUNCTIONAL    DISORDERS.  317 

fluence  over  the  secretion  of  the  stomach.  When,  therefore,  we 
find  dyspeptic  symptoms  associated  with  the  aspect  of  thin  and  poor 
blood,  the  only  question  can  be  whether  they  are  wholly  dependent 
upon  the  anaemia,  or  have  any  separate  cause ;  and  this  is  best  known 
by  ascertaining  which  class  of  symptoms,  the  dyspeptic  or  the 
anaemic,  had  the  priority  in  commencement.  And  if  the  complex 
disorder  began  by  the  imperfect  action  of  the  stomach  withholding 
the  due  supply  of  pabulum  to  the  blood,  we  must  still  admit  that 
the  consequent  anaemia  will  aggravate  the  dyspeptic  symptoms ;  just 
as  we  know  that  imperfect  digestion,  though  caused  by  anaemia, 
necessarily  tends  to  increase  that  state.  It  is  probably  in  this  way 
that  bad  food  and  chronic  wasting  diseases  excite,  as  they  occasion- 
ally do,  persisting  forms  of  dyspepsia,  as  they  necessarily  deterio- 
rate the  quality  of  the  blood:  bad  food  does  not  primarily  excite 
permanent  disorder. 

(3.)  In  some  forms  of  disease  a  specific  blood-crasis  seems  to 
exist,  which  has  a  close  relation  to  the  secretion  of  the  stomach. 
To  this  class  we  might  legitimately  refer  the  inaptitude  for  digestion 
p'roduced  by  inflammatory  and  febrile  diseases ;  but  it  must  rather 
be  restricted  to  indigestion  arising  in  the  gouty  diathesis,  the  dys- 
pepsia of  drunkards,  &c.  In  other  cases  the  dyspepsia  is  more 
distinctly  associated  with  disturbance  of  brain  and  mental  excite- 
ment; when  it  becomes  difficult  to  say  whether  the  effect  be  produced 
through  the  medium  of  the  blood  or  of  the  nerves. 

(4.)  There  yet  remain  very  numerous  instances  of  dyspepsia,  in 
which  faulty  secretion  seems  to  be  the  principal  cause  of  the  defect 
in  the  digestive  power,  where  we  cannot  trace  it  back  to  any  ante- 
cedent circumstances,  and  cannot  explain  the  agency  by  which  it 
has  been  established.  Among  them  we  include  cases  characterized 
by  heartburn,  pyrosis,  flatulence,  nausea,  loathing  of  food,  vomiting, 
disagreeable  tastes  in  the  mouth,  &c,  which  occasionally  occur  in 
persons  in  comparative  health,  and  are  found  to  yield  to  the  simplest 
treatment,  but  which,  in  their  habitual  persistence,  become  so  rebel- 
lious and  intractable. 

.  Under  any  of  these  circumstances  the  secretion  of  the  stomach 
may  be  very  variously  modified.  Thus,  it  may  be  deficient  in  the 
special  principle  (pepsine,)  which  acts  as  a  solvent  of  the  albuminous 
substances ;  all  animal  food  whatever  will  be  found  by  the  patient 
difficult  of  digestion;  and  as  a  consequence  of  its  imperfect  solu- 
tion, fetid  gases  will  be  evolved,  and  unaltered  fibres  will  be  seen 
in  the  evacuations;  or,  again,  the  secretion  may  be  of  such  a  cha- 
racter as  to  set  up  a  process  of  fermentation  rather  than  digestion, 
with  the  development  of  acid  and  flatus,  which  is  very  constantly 
associated  with  diarrhoea:  or  there  maybe  excessive  secretion,  of 
feeble  power,  rising  up  and  filling  the  mouth  with  tasteless  fluid 
when  the  stomach  is  empty.  The  first  of  these  is  the  condition 
most  frequently  resulting  from  strain  of  mind;  the  second  is  the 
common  precursor  of  gout;  the  third  is  the  usual  result  of  bad 


318      DISEASES    OF    THE    (ESOPIIAGUS   AND   STOMACH. 

and  insufficient  nutriment:  but  each  of  them  may  be  met  with  casu- 
ally, or  even  persisting  for  a  considerable  period,  without  any  such 
definite  causes. 

This  short  sketch  would  be  incomplete  if  no  allusion  were  made 
to  the  spasmodic  pain  which  attacks  persons  subject  to  gouty  dys- 
pepsia, and  commonly  known  as  gout  in  the  stomach.  Its  plaee 
would  seem  to  be  in  that  class  of  cases  in  which  irritability  is  a 
prominent  symptom,  as  it  is  especially  marked  by  violent  pain  in 
the  epigastric  region ;  it  is  generally,  however,  preceded  by  symp- 
toms of  faulty  secretion,  and  passes  off  with  a  discharge  of  flatu3 
from  the  stomach. 

It  has  been  already  stated  that  dyspepsia  is  frequently  associated  with  other 
chronic  diseases:  we  especially  look  for  anaemia  and  emaciation  in  its  slighter 
forms;  and  in  females  for  hysteria  and  functional  derangements  of  the  uterine  or- 
gans. Among  its  causes  we  must  not  forget  the  possible  effect  of  deleterious 
agents;  not  only  those  which  are  distinctly  recognised  as  poisons,  but  those  also 
which  bear  the  name  of  luxuries,  such  as  tobacco  and  fermented  liquors.  Tuber- 
cular diseases  may  give  rise  to  symptoms  of  dyspepsia,  and  they  are  occasionally 
also  first  betrayed  by  them.  The  condition  of  the  liver  and  the  functions  of  the 
brain  must  be  each  inquired  into,  both  as  causes  and  complications  of  disordered 
stomach.  Changes  in  the  character  of  the  urine  will  be  found  sometimes  depend- 
ent solely  on  the  mal-assimilation  of  nutriment;  and  sometimes,  while  affording 
evidence  of  disorders  especially  referrible  to  the  kidney,  are  still  very  much  in- 
fluenced by  the  condition  of  the  digestion.  Skin  diseases,  in  like  manner,  have  a 
very  close  relation  to  dyspepsia. 


319 


CHAPTER  XXVII. 

DISEASES   OF    THE    INTESTINAL    CANAL. 


•imary.  Division — General  Relations  of  Inflammation. 

V.  I. — Diseases  attended  with  Constipation. — §  1,  Constipation — 


Prima, 

Div.  _ 

§  2,  Enteritis— •§  3,  Ileus—  §  4,  Obstruction. 

pIV,  n. — Diseases  attended  with  Relaxation. — §  1,  Diarrhoea — 
§  2,  Dysentery — §  3,  Ulceration. 

Div.  III. — Diseases  attended  with   altered  Secretion. — §  1,  Dis- 
ordered Bowels — §  2,  Tympanites. 

All  diseases  of  the  intestinal  canal  have  one  feature  in  common, 
that  they  are  accompanied  either  by  constipation  or  relaxation,  or 
by  an  alteration  of  these  two  states.  This  is  detailed  as  part  of 
the  necessary  history  of  the  case;  and  it  again  comes  before  us  in 
the  inquiry  which  we  have  supposed  it  necessary  to  make  into  the 
evidences  of  the  general  state  of  the  patient  before  commencing 
the  investigation  of  individual  organs:  it  will  therefore,  perhaps, 
best  serve  our  present  purpose  to  adopt  this  common  feature  as  the 
basis  of  classification,  and  so  follow  out  the  symptoms  which  are 
available  in  discriminating  the  various  conditions  which  these  cir- 
cumstances serve  primarily  to  indicate. 

It  is  necessary,  before  proceeding  further,  to  make  a  few  remarks  on  the  subject 
of  inflammation,  to  point  out  more  clearly  its  relations  to  the  action  of  the  bowels. 
Idiopathic  gastritis  is  almost  unknown:  peritonitis,  as  we  shall  see,  is  more  com- 
mon: inflammation  of  the  stomach  is  sometimes  conjoined  with  that  of  the  peri- 
toneum; but  inflammation  of  the  bowels  is  so  more  frequently,  in  consequence  of 
their  greater  extent  of  surface. 

Enteritis,  as  a  primary  affection,  holds  a  position  in  regard  to  frequency  be- 
tween gastritis  and  peritonitis;  but  even  when  the  inflammation  seems  to  have 
begun  in  the  bowel,  it  is  almost  always  found  to  have  affected  the  peritoneum ;  so 
that  in  general  it  is  not  easy  to  say  which  disease  has  been  first  in  the  order  of 
succession.  The  cases  of  enteritis  "without  peritoneal  inflammation  are  among  the 
curiosities  of  medical  literature;  and  possibly  the  highly  susceptible  membrane  of 
the  peritoneum  is  the  first  to  take  on  inflammatory  action,  whether  the  irritation 
have  been  conveyed  to  it  from  within  or  from  without.  The  disease  known  as 
enteritis  consists  of  inflammation  involving  all  the  structures  and  especially  the 
muscular  coat  of  the  canal;  and  by  common  consent,  inflammation  of  the  mucous 
membrane  alone  is  not  meant,  when  the  name  enteritis  is  employed.  A  know- 
ledge of  these  relations  is  of  great  importance  in  symptomatology;  because,  first, 
the  inflammation  involving  the  peritoneum  produces  great  tenderness  on  pressure; 
secondly,  the  inflammation  of  muscle  produces  paralysis,  with  interruption  of  pe- 
ristaltic action  and  constipation;  and  thirdly,  the  inflammation  of  other  mucous 
membranes  teaches  us  that  the  primary  effect  may  be  suppressed  secretion ;  but 
that  this  is  soon  replaced  by  increased  and  altered  secretion,  perhaps  by  effusion 
of  blood — active  hemorrhage. 


320  DISEASES   OF   THE   INTESTINAL   CANAL. 

Div.  I. — Diseases  attended  with  Constipation. 

§  1.  Constipation. — Let  us  assume  that  the  other  indications  of 
the  general  state  of  health  do  not  point  to  any  febrile  disorder. 
The  tongue  indeed  may  be  coated,  and  the  appetite  bad;  but  thirst 
is  not  urgent,  the  skin  has  no  unnatural  heat,  and  the  pulse  is  quiet: 
any  specialty  of  the  urine  must  be  considered  separately.  In  this 
simple  form  the  patient  merely  seeks  a  remedy  for  constipation  of 
the  bowels.  We  inquire  into  the  condition  of  the  stomach,  and 
most  commonly  find  some  indication  of  dyspepsia;  and  it  may  be 
a  question  which  of  the  two  is  primary:  we  seek  also  for  evidence 
of  biliary  derangement,  knowing  this  secretion  to  be  of  paramount 
importance  in  aiding  the  expulsion  of  the  feces. 

In  such  a  case  we  derive  much  information  from  its  history:  the 
progress  of  the  disorder  has  been  gradual;  the  patient  has  had 
costive  bowels  for  years  probably,  before  he  has  consulted  any  one 
on  the  subject;  he  has  taken  aperients,  and  then  again  has  tried  to 
do  without.  His  habits  next  serve  to  point  out  the  nature  of  the 
evil:  he  has  perhaps  led  a  sedentary  or  irregular  life;  and  in  addi- 
tion to  this,  his  food  may  have  been  either  luxurious  and  over-stimu- 
lant, inducing  plethora;  or  it  may  have  been  the  reverse,  and  he 
has  become  anaemic.  Patients,  too,  as  they  consider  themselves 
competent  to  manage  their  own  bowels,  have  something  else  to  com- 
plain of  when  they  seek  advice — head-ache,  occasional  colic,  or 
congestion  of  the  lower  abdominal  viscera,  resulting  in  hemor- 
rhoids, or  in  uterine  hemorrhage  or  leucorrhoea. 

The  two  principal  causes  of  constipation  seem  to  be  deficient  se- 
cretion and  want  of  peristaltic  action:  plethora  rather  points  to  the 
former,  general  anemia,  or  atony  to  the  latter.  But  in  the  end, 
accumulation  of  feculent  matter  proceeds,  the  muscular  fibres  are 
necessarily  stretched,  and  become  incapable  of  contracting  effi- 
ciently: the  fluid  portion  is  absorbed,  and  masses  of  hard  impacted 
faeces  remain  in  the  bowels.  Just  as  in  other  involuntary-  muscles, 
the  constant  result  of  over-tension  and  imperfect  power,  is  spas- 
modic and  irregular  action — colic,  of  which  a  very  important  variety 
has  been  mentioned  as  the  effect  of  lead  poisoning:  the  symptom 
is  the  same,  Avhether  there  be  lead  in  the  system  or  not;  but  the 
blue  line  indicating  its  presence  ought  in  such  circumstances  always 
to  be  sought  for  (see  Chap.  VI.,  Div.  I.,  §  3.)  A  very  important 
result  of  this  imperfect  action  is,  that  the  feces  get  impacted  and 
indurated  in  the  colon  and  rectum :  this  is  followed  by  thin  watery 
secretions,  which  find  their  way  past  the  hardened  mass,  and  lead 
the  patient  to  imagine  that  he  is  suffering  from  diarrhoea,  and  to 
use  astringents,  which  increase  the  disorder.  The  abdomen  becomes 
tumid;  dull  percussion  sound  on  the  left  side  and  over  the  brim  of 
the  pelvis  indicates  the  existence  of  accumulation;  and  when  pur- 
gatives fail  to  act,  it  may  be  suspected  that  there  is  some  physical 
impediment  to  its  egress,  and  the  case  puts  on  the  characters  of 
obstruction. 


ENTERITIS.  321 

§  2.  Unteritis. — This  disease  is  only  distinguished  from  other 
forms  of  obstruction  by  the  presence  of  fever:  it  is  accompanied 
by  inaction  of  the  bowels  after  the  administration  of  purgative 
medicine,  pain  of  every  variety  of  intensity,  and  vomiting,  which 
is  apt  to  become  fceculent  or  stercoraceous. 

A  broad  line  of  distinction  is  first  found  between  those  cases 
commencing  suddenly  without  previous  constipation,  and  those  in 
which  the  attack  is  a  mere  aggravation  of  a  pre-existing  state. 
Colic  has  been  mentioned  as  one  of  the  results  of  habitual  costive- 
ness ;  but  it  is  still  more  common  when  constipation  i3  caused  by 
some  error  in  diet,  or  by  some  hardened  mass  unexpectedly  inter- 
rupting the  progress  of  the  excrementitious  matters,  when  the  bowels 
had  been  acting  regularly ;  it  occurs  as  a  spasmodic  and  grinding 
or  twisting  pain,  which  is  not  at  first  accompanied  by  tenderness, 
but,  on  the  contrary,  is  relieved  by  pressure.  This  circumstance 
serves  at  once  to  distinguish  it  from  that  of  peritoneal  inflammation: 
it  is  more  liable  to  be  confounded  with  the  pain  caused  by  the  pas- 
sage of  a  gall-stone  (see  Chap.  XXIX.,  Div.  I.,  §  5.)  By  judicious 
treatment  the  peristaltic  action  perhaps  once  more  returns  to  regu- 
larity, the  bowels  are  evacuated,  and  the  patient  is  restored  to  health. 
But  if  the  remedies  fail,  the  pain  is  soon  accompanied  by  tender- 
ness, the  spasmodic  action  ceases,  and  is  followed  by  paralysis,  in  con- 
sequence of  inflammation ;  febrile  symptoms  are  developed,  medicines 
are  rejected  by  vomiting,  and  no  action  of  the  bowel  takes  place; 
the  pain  is  more  permanent,  its  exacerbations  and  intermissions  are 
less  marked ;  in  short,  enteritis  has  supervened  in  consequence  of 
the  obstruction,  and  there  is  more  or  less  of  its  accompanying  peri- 
tonitis: in  the  further  progress  of  the  disease,  the  abdomen  becomes 
tense  and  tympanitic,  the  pulse  small  and  thready,  vomiting,  which 
is  partly  stercoraceous,  is  followed  by  hiccup,  and  collapse,  and 
death. 

These  symptoms,  however,  may  be  developed  without  the  pre- 
vious existence  of  any  thing  resembling  colic;  tenderness  may  exist 
from  the  first,  and  the  inflammation  may  have  arisen  without  the 
intervention  of  any  obstructing  cause;  and  then  it  has  probably 
travelled  from  without,  beginning  in  partial,  local  peritonitis,  and 
obstruction  only  occurring  as  a  consequence  of  the  inflammation  of 
the  bowel.  In  both  classes  the  existence  of  the  inflammation  is 
shown  by  the  permanence  of  pain,  the  presence  of  tenderness,  and 
the  existence  of  febrile  action ;  and  the  question  as  to  what  was 
the  exciting  cause  is  one  of  minor  importance.  Indeed,  any  history 
which  seems  to  point  to  obstruction,  and  the  prominent  symptom  of 
inaction  of  the  bowels,  are  both  very  apt  to  lead  us  away  from  the 
important  fact  of  enteritis  being  really  present. 

§  3.  Ileus  and  Intussusception. — Physicians  of  the  largest  expe- 
rience and  most  comprehensive  judgment  have  failed  to  deduce 
from  the  symptoms,  indications  which  can  be  regarded  wholly  trust- 
21 


022  DISEASES    OF    TIIE    INTESTINAL    CANAL. 

worthy  as  to  the  nature  of  this  disease.  Its  commencement  is  very 
analogous  to  the  first  form  of  enteritis  just  spoken  of:  the  colic  is 
more  severe;  there  is  usually  complete  remission  of  pain  for  a 
while,  which  again  returns  with  increased  violence.  In  contrast  to 
simple  colic,  the  spasm  is  more  regular  in  its  recurrence,  there  is 
less  sensation  of  twisting  and  grinding,  and  more  of  a  continued 
paroxysm,  caused  by  the  violent  and  energetic  action  of  the  muscu- 
lar fibre  to  overcome  the  obstruction:  the  large  coils  of  intestine 
may  sometimes  be  felt  rolling  and  turning  over  in  the  abdomen 
during  its  continuance.  In  the  progress  of  the  disease  when  the 
bowel  is  inverted,  paralysis  of  fibre  induced  by  inflammation,  acts 
as  a  further  impediment,  but  primarily  the  obstacle  is  mechanical. 

As  in  enteritis,  the  cause  of  its  occurrence  may  be  the  presence 
of  some  solid  mass  in  the  intestine :  the  symptoms  of  the  two  affec- 
tions are  therefore  often  intermingled  together,  and  the  success  of 
treatment  may  depend  on  a  discrimination  of  their  coexistence.  In 
the  first-mentioned  form  of  enteritis,  for  example,  a  very  limited 
amount  of  inflammation  in  the  immediate  proximity  of  the  solid  sub- 
stance may  give  rise  to  manifest  and  characteristic  evidence  of  some 
form  of  obstruction;  and  yet,  on  the  fact  of  the  practitioner  recog- 
nising and  obviating  the  slighter  and  less-marked  condition  of  local 
inflammation,  may  entirely  rest  the  safety  of  his  patient. 

Closely  resembling  intus-susception  are  those  cases  in  which  the 
bowel  is  enclosed  in  a  band  of  adhesion  when  at  first  there  is  no  in- 
flammation :  the  history  maybe  simply  that  the  bowels  have  not  acted, 
that  medicine  has  been  taken  without  effect,  that  sickness  has  come 
on,  and,  finally,  that  paroxysms  of  pain  have  recurred  at  intervals: 
or  the  order  may  be  inverted,  violent  pain  having  first  occurred, 
accompanied  by  vomiting  from  the  commencement;  and  it  is  only 
discovered  at  a  later  period  that  the  bowels  will  not  act:  or,  again, 
the  vomiting  may  be  absent  in  either  case  for  a  considerable  period. 
In  all  of  them  there  is  ultimately  more  or  less  of  inflammation  set 
up ;  and  if  the  patient  be  not  seen  till  then,  hope  may  for  a  short 
time  linger  over  the  possibility  of  relief  following  on  the  use  of 
antiphlogistic  measures,  which  is  only  dissipated  by  the  utter  fu- 
tility of  the  most  judicious  treatment. 

§  4.  Obstruction. — The  rules  of  diagnosis  are  so  obscure,  that  a 
large  number  of  cases  must  be  classed  under  this  head  of  which  the 
only  fact  known  is  that  the  bowels  obstinately  refuse  to  act:  but  as 
in  enteritis  we  found  that  very  generally  the  attack  commenced  either 
with  colic  or  tenderness  on  pressure,  that  in  ileus  the  stoppage  oc- 
curred suddenly  without  previous  derangement  of  bowels,  so  we  find 
in  this  class  that  long-continued  constipation  has  usually  preceded 
the  obstruction.  Here  we  have  clearly  two  possible  states — a  gra- 
dually diminishing  calibre  of  the  bowel,  or  a  condition  of  extreme 
distention  from  long  standing  accumulation  and  impaction,  which 
are  both  quite  different  from  those  already  referred  to ;  but  the  mere 


OBSTRUCTION.  323 

fact  of  habitual  constipation,  although  of  great  importance,  does 
not  necessarily  indicate  either  condition ;  the  habit  may  exist  with- 
out the  evil  effect.  In  cases  of  obstruction  we  have  the  additional 
fact  of  the  bowels  being  loaded  with  feculent  matter:  when  no  or- 
ganic disease  exists,  this  always  occupies  the  lower  end  of  the  colon ; 
when  pressure  from  without  is  the  cause  of  obstruction,  the  accu- 
mulation will  also  generally  be  found  where  the  bowel  is  fixed  near 
its  outlet:  stricture  usually  affects  the  rectum  or  the  lower  part  of 
the  colon.  In  some  rare  cases  it  happens  that  the  narrowed  portion 
is  found  high  up,  and  then  large  accumulation  cannot  take  place;  in 
such  instances  there  is  a  great  resemblance  to  ileus. 

In  cases  of  obstruction  we  derive  much  help  from  physical  dia- 
gnosis. Having  first  learned  the  fact  of  constipation,  we  endeavour 
by  palpation,  to  discover  the  position  of  the  distended  bowel ;  the 
pelvis  must  be  explored  in  search  of  a  tumour  which  might  press  on 
the  canal  from  without;  and,  lastly,  the  rectum  itself  must  be  ex- 
amined to  determine  the  presence  of  impacted  faeces,  or  discover  the 
position  of  stricture  by  digital  examination  and  the  introduction  of 
instruments.  This  exploration  ought  never  to  be  omitted  when  the 
bowels  are  obstructed;  and  much  light  is  always  to  be  obtained  from 
the  simple,  and  it  may  be  said  necessary  employment  of  injections. 
When  carefully  performed,  the  amount  of  liquid  that  can  be  slowly 
injected  into  the  canal  may  be  said  to  be  a  direct  measure  of  the 
extent  of  permeable  intestine  situated  below  the  obstruction.  In 
all  cases  in  which  it  is  towards  the  lower  part  of  the  bowels,  vomiting, 
if  prolonged  or  repeated,  is  apt  to  present  a  stercoraceous  character. 

One  or  two  points  afford  occasional  aid  in  determining  the  position  and  charac- 
ter of  the  obstruction.  If  the  point  at  which  pain  is  felt  be  also  that  at  which  we 
can  trace  the  transition  from  a  distended  to  a  collapsed  and  empty  state  of  the 
canal,  we  may  feel  pretty  sure  that  this  is  the  point  of  obstruction :  the  condition 
of  the  colon,  which  through  its  whole  extent  is  comparatively  fixed  and  immove- 
able, especially  demands  examination  with  this  view.  Both  symptoms,  however, 
are  apt  to  be  indefinite — the  pain  extending  over  the  whole  abdomen — the  rela- 
tion of  the  distended  portion  to  the  rest  of  the  intestine  not  to  be  recognised:  and 
this  is  especially  true  when  the  small  intestine  is  affected. 

A  less  trustworthy  sign  is  derived  from  the  urinary  secretion,  which  is  generally 
scanty  when  the  obstruction  is  high  up,  and  more  abundant  when  it  is  situated 
lower  down.  This  is  very  liable  to  be  interfered  with  by  other  circumstances,  such 
as  the  existence  of  fever.  Still  less  reliance  is  to  be  placed  on  the  allegation  that 
vomiting  comes  on  earlier,  aud  is  more  distressing  when  the  obstruction  is  high  up. 

Of  the  cases  of  sudden  stoppage,  it  may  be  said  in  general  terms,  that  about 
one-third  are  due  to  intus-susception,  one-third  to  some  form  of  internal  strangu- 
lation, and  scarcely  one-third  to  all  other  causes  together.  We  incline  to  believe 
the  cause  of  the  obstruction  to  be  invagination,  if  a  little  bloody  mucus  be  passed 
by  stool,  if  a  sudden  pain  were  felt  before  vomiting  had  been  experienced,  and 
when  constipation  had  not  been  known  to  exist;  we  more  readily  assume  that  the 
gut  is  strangulated  by  a  band  of  adhesion,  if  we  can  make  out  from  the  patient's 
history  that  he  has  had  an  attack  of  abdominal  inflammation  at  any  previous  pe- 
riod: in  their  subsequent  progress  the  former  is  more  frequently  associated  with 
inflammatory  fever  than  the  latter. 

By  far  the  greater  number  of  cases  of  gradual  obstruction  depend  on  stricture, 
too  frequently  cancerous:  it  is  scarcely  necessary  to  allude  to  an  appearance  oc- 
casionally observed,  that  the  fteces  have  been  for  some  time  previously  of  small 


32-4      DISEASES  OF  TEE  INTESTINAL  CANAL. 

diameter,  because  in  such  a  case  the  constriction  of  the  bowel  must  be  quite  within 
the  reach  of  physical  examination.  But,  it  may  be  observed,  that  a  previous  his- 
tory <>('  long-continued  diarrhoea,  with  unhealthy  discbarges  of  pus,  blood,  &c, 
the  probability  of  contraction  as  a  sequence  of  the  ulcerative  process 
at  a  burlier  portion  of  the  canal. 

Enteritis  has  to  be  distinguished  from  peritonitis,  with  which  in  some  cases  it 
Stands  in  very  close  relation:  it  is  very  apt  to  be  simulated  by  calculous  or  gouty 
iralgia.  The  other  forms  of  obstructive  disease  are  more  nearly  allied  to  her- 
nia; it  is,  indeed,  sometimes  an  internal  hernia,  which  is  only  irremediable  in  so 
as  it  is  removed  from  manual  interference:  great  blame  is  justly  due  to  the 
practitioner  who  omits  examining  every  part  where  a  hernia  may  possibly  come 
within  reach  of  relief  in  a  case  of  insuperable  constipation. 

Division  II. — Diseases  attended  with  Relaxation. 
$  1.  Diarrhoea. — We  now  come  to  those  conditions  of  the  in- 

%j  e 

testinal  canal  which  are  marked  by  excessive  action  of  the  bowels: 
they  are  chiefly  dependent  on  the  state  of  the  mucous  membrane, 
including  in  that  term  the  whole  secreting  apparatus.  The  dis- 
orders of  this  class  may  be  formed  into  several  distinct  groups,  from 
a  consideration  of  their  history  and  attendant  phenomena. 

a.  With  no  heat  of  skin  or  quickness  of  pulse,  we  have  (1)  a 
history  of  previous  constipation,  when  slight  watery  discharges  are 
taking  place,  in  consequence  of  the  irritation  of  the  mucous  mem- 
brane by  the  accumulation:  (2)  the  ingestion  of  some  unhealthy  ali- 
ment, or  of  a  larger  quantity  of  food  than  the  stomach  can  digest, 
which,  passing  into  the  intestines,  causes  irritation  there.  In  both 
of  these  cases  there  is  usually  pain  and  a  foul  tongue ;  the  action  is 
a  preservative  one,  by  which  nature  seeks  to  expel  the  offending 
material,  and,  if  opposed,  dangerous  inflammation  and  obstruction 
may  result.  (3)  This  reaction  may  have  served  to  remove  the  source 
of  irritation,  and  yet  the  diarrhoea  may  persist  merely  as  an  ex- 
cessive secretion  set  up  by  the  irritation  and  congestion  of  the  mem- 
brane. (4)  The  irritation  may  be  the  effect  of  exposure  to  changes 
of  temperature  analogous  to  the  more  common  effects  of  cold  on  the 
bronchial  membrane.  Of  this  kind  seems  to  be  that  form  of  diar- 
rhoea which  is  often  prevalent  in  summer  when  the  tongue  is  coated, 
the  stools  dark,  and  there  are  griping  pains  in  the  abdomen.  (5)  The 
genuine  summer  cholera,  on  the  other  hand,  is  marked  by  copious, 
pale,  watery  evacuations,  with  a  clean  tongue,  a  cold  skin,  and  no 
abdominal  pain ;  it  is  exactly  like  the  choleraic  diarrhoea,  which  at- 
tends the  spread  of  epidemic  cholera.  (6)  There  is  also  a  very  well- 
marked  form  dependent  on  disorder  of  the  liver  and  excessive  secre- 
tion of  bile,  to  which  the  name  of  bilious  diarrhoea  is  not  inappropriate ; 
it  is  most  commonly,  however,  associated  with  excesses  in  eating 
and  drinking,  and  is  consequently  allied  with  the  class  of  cases 
caused  by  indigestion. 

b.  When  general  symptoms  are  present  they  belong,  in  a  large 
number  of  cases,  to  some  other  disease,  of  which  diarrhoea  is  also 
only  symptomatic. 

To  determine  this  point  we  must  refer  to  the  modes  of  investiga- 


DYSENTERY.        .  325 

tion  and  sources  of  information  enumerated  in  treating  of  these  dis- 
eases themselves;  as  the  most  common  we  may  mention  continued 
fever  with  bowel-symptoms,  tubercukr  diseases,  and  albuminuria. 
In  the  first  two  it  is  always  accompanied  by  ulceration,  in  the  lat- 
ter the  secretion  seems  to  be  often  vicarious  of  that  of  the  kidney. 

c.  Diarrhoea,  with  febrile  symptoms  which  are  not  referrible  to 
any  other  disease,  is  more  frequently  seen  in  this  country  in  child- 
hood than  in  adult  life.  Inflammation  of  the  mucous  membrane, 
with  a  tendency  to  ulceration,  is  the  pathological  condition  which, 
in  its  fullest  development,  is  only  met  with  in  dysentery.  The 
tongue  is  coated,  the  pulse  quick,  the  skin  hot,  with  much  thirst ; 
the  bowels  continue  for  some  days  to  act  very  many  times,  and  the 
stools  soon  become  slimy  and  mixed  with  blood:  among  children 
there  is  very  often  prolapsus  ani;  then  follow  the  appearances  of 
putrid  flesh  and  fetid  puriform  matter,  corresponding  to  the  analo- 
gous appearances  in  true  dysentery.  But  the  symptoms  may  stop 
short  of  this  extreme  condition,  and  then  it  is  often  hard  to  distin- 
guish them  from  those  of  dental  irritation;  there  is  nothing  indeed 
to  show  that  the  latter  may  not  pass  into  inflammation,  and  in  in- 
fantile life  it  is  a  very  frequent  source  of  febrile  diarrhoea. 

Again,  we  more  frequently  see  the  condition  of  membrane  which 
is  characterized  by  aphthse  of  the  mouth  and  fauces  in  childhood, 
than  we  do  in  adult  life,  and  we  may  be  even  more  certain  that  in 
the  former  it  is  not  a  local  malady  from  a  similar  condition  exist- 
ing at  the  anus. 

d.  Chronic  diarrhoea  is  very  often  dependent  on  ulceration ;  but 
we  have  abundant  proof  that  it  also  sometimes  persists  for  long  pe- 
riods without  any  indication  of  such  a  condition  from  the  character 
of  the  stools.  Many  persons  are  subject  to  it  from  the  most  trivial 
causes :  and  the  complaint  is  often  very  obstinate  in  childhood,  and 
yet  the  ultimate  complete  recovery  proves  that  no  structural  change 
has  occurred.  In  other  instances  it  depends  on  disease  of  the  me- 
senteric glands,  and  is  only  one  form  of  its  association  with  tuber- 
cles in  early  life. 

§  2.  Dysentery. — This  disease,  which  was  at  one  time  much  more 
common  in  our  own  country  than  it  now  is,  still  continues  to  be  one 
of  the  most  serious  affections  of  tropical  climates.  It  presents  to 
us  the  most  severe  form  of  .inflammation  of  the  mucous  membrane, 
tending  to  very  extensive  ulceration. 

In  its  pathological  relations  it  is  probably  allied  to  acute  diarrhoea  with  great 
irritation :  the  instances  are  perhaps  more  numerous  than  we  are  aware  of  in  which 
the  local  action  predominates,  and  the  fever  is  only  symptomatic,  though  they  be 
at  present  regarded  as  fever  with  bowel  complication,  except  when  symptoms  arise 
which  are  more  distinctly  dysenteric.  Such  appearances  can  only  be  seen  when 
the  large  intestine  is  the  principal  site  of  the  diseased  action,  because,  if  it  were 
confined  to  the  upper  part  of  the  bowel  while  the  colon  remained  healthy,  the  se- 
cretions would  be  so  changed  in  their  passage  that  the  peculiar  characters  could 
not  be  observed :  and  indeed  this  is  in  part  true  of  dysentery  itself  as  affecting  dif- 


32G  DISEASES    OF    THE    INTESTINAL   CANAL. 

ferent  portions  of  the  colon.  On  the  other  hand,  there  are  pood  reasons  for  re- 
garding true  dysentery  as  something  quite  distinct  from  affections  of  the  small  in- 
testine in  which  febrile  symptoms  are  present;  and  perhaps  as  we  have  ceased  to 
regard  t he  ulceration  of  the  ileum  as  an}- tiling  more  than  a  symptom  of  common 
bowel  fever,  we  ought  to  regard  the  ulceration  of  the  colon  only  as  a  symptom  ot 
another  " lever;"'  at  all  events,  we  find  that,  as  in  the  one  the  ulceration  seldom 
affects  the  colon,  and  then  only  in  its  upper  end,  so  in  the  other,  the  ulceration 
seldom  extends  any  distance  from  the  colon  into  the  small  intestine. 

The  chief  symptom  relied  on  in  dysentery  is  the  passing  of  bloody 
mucus  with  hardened* scybalous  masses  of  faecujent  matter;  but  this 
is  really  the  evidence  of  a  mild  attack,  in  which  the  lower  part  of 
the  colon  is  alone  involved.  In  the  severer  cases  diarrhoea  first 
comes  on,  emptying  the  whole  of  the  large  intestine ;  and  only  sub- 
sequently do  bloody  and  mucous  discharges,  with  tenesmus,  occur. 
Its  commencement  is  generally  sudden,  with  pain  in  the  abdomen, 
in  the  hypogastrium,  and  perhaps  especially  on  the  left  side:  if  the 
lower  end  of  the  colon  only  suffer,  the  faeces  from  above  are  passed 
as  scybala;  glairy  bloody  mucus  is  discharged,  which  in  a  short 
time  becomes  purulent  and  offensive,  and  as  ulceration  proceeds  a 
greater  amount  of  hemorrhage  generally  continues:  tenesmus  is  al- 
ways a  distressing  symptom,  and  is  sometimes  conjoined  with  irri- 
tation of  the  bladder  and  the  urethra.  When  the  pyrexia  is  not 
very  evident,  it  is  of  importance  to  ascertain  that  the  blood  does  not 
come  from  the  rectum,  where  local  disease  may  exist,  either  in  the 
form  of  hemorrhoids,  or  as  cancerous  or  fungoid  growth. 

Chronic  dysentery  might  also  be  classed  under  ulceration,  for 
under  no  other  circumstances  does  ulceration  proceed  so  far;  but 
we  have  reason  to  regard  it  as  a  specific  disease,  as  it  generally  fol- 
lows on  an  acute  attack:  the  patient  has  probably  been  in  a  tropi- 
cal climate,  the  bowels  have  since  been  always  irregular,  the  motions 
unhealthy,  commonly  mingled  with  pus  or  muco-purulent  secretion, 
and  often  with  blood.  The  disease,  however,  remains  quiescent  until 
something  arouses  it  to  fresh  activity;  some  disorder  of  stomach,  or 
exposure  to  cold  or  wet  brings  on  a  partially  acute  attack:  or  else, 
from  the  extensive  disorganization  which  has  occurred,  enormous 
accumulations  arise  in  the  colon,  which  it  is  unable  to  propel:  these 
cannot  be  effectually  got  rid  of  by  the  aid  of  remedies ;  low,  wasting, 
suppurative  fever  supervenes,  with  gradual  exhaustion,  or  the  dis- 
eased structure  is  attacked  by  low  inflammation,  terminating  in  a 
condition  allied  to  sphacelus. 

§  3.  Ulceration. — Little  can  be  said  to  elucidate  this  form  of 
bowel-ailment.  We  know  it  to  exist  in  phthisis,  and  in  continued 
fever:  and  in  either  case  when  there  is  irritability  of  the  canal,  with 
watery,  unhealthy,  and  frequently  fetid  stools,  and  the  tongue  is 
glazed  or  aphthous,  we  have  good  grounds  for  concluding  that  ulce- 
ration is  going  on.  We  may,  perhaps,  also  be  justified  in  predi- 
cating it,  when  in  other  instances  similar  conditions  persist,  in  spite 
of  treatment,  and  we  are  unable  to  discover  any  other  disorder  of 


ALTERED    SECRETIONS.  327 

the  abdominal  viscera  to  account  for  their  presence.  It  is^not  com- 
mon as  an  idiopathic  disease,  and  it  may  exist  for  long  periods  with- 
out giving  rise  to  any  distinct  symptoms  at  all. 

Hemorrhage  is  perhapsione  of  the  most  certain  indications  when  it  occurs  spon- 
taneously and  in  considerable  quantity;  the  appearance  of  the  blood,  in  some 
measure,  aids  in  determining  from  what  portion  of  the  canal  it  comes,  because  its 
colouring  matter  is  very  readily  acted  on  by  the  secretion  of  the  bowels,  and  can 
only  present  a  florid  aspect  when  the  point  of  its  discharge  is  situated  near  the 
anus:  the  colour  is  otherwise  black,  and  hence  the  name  of  "melasnt,"  has  been 
given  to  this  form  of  hemorrhage.  Evacuations  of  similar  character  occur  when 
the  blood  comes  from  the  stomach,  and  the  blackest  and  most  pitchy  evacuations 
are  seen  when  this  is  their  source.  Hrematemesis  would  of  course  determine  that 
blood  had  been  effused  into  the  stomach  itself,  but,  though  a  common  consequence 
of  its  presence,  it  is  by  no  means  essential,  and  must  not  be  made  the  basis  of  an 
absolute  rule  in  diagnosis. 

The  presence  of  pus  in  the  stools  can  only  indicate  ulceration  low  down  in  the 
canal:  its  quantity  cannot  be  large,  unless  the  ulcerated  surface  be  such  as  is  seen 
in  dysentery,  and  its  admixture  with  feculent  matter  must  necessarily  alter  its  cha- 
racters and  prevent  its  recognition  if  it  pass  through  any  great  length  of  the  intes- 
tine. A  red  and  glazed  tongue,  with  a  tendency  to  the  formation  of  aphthous 
crusts,  has  been  before  alluded  to  as  indicating  a?general  state  of  the  mucous 
membrane  which  is  disposed  to  ulceration;  it  is  seldom  noticed,  however,  except  in 
cases  of  phthisis  or  bowel-fever. 

Drv.  III. — Diseases  attended  with  altered  Secretion. 

It  might  very  fairly  be  argued  that  many  cases  of  which  consti- 
pation is  a  prominent  symptom,  and  all  of  those  attended  with 
diarrhoea,  should  be  classed  under  this  division.  Our  object,  how- 
ever, is  not  pathological  accuracy,  but  simplicity  of  arrangement, 
and  we  have  now  to  do  with  cases  in  which  either  diarrhoea  is  con- 
tinually alternating  with  constipation,  or  the  evacuations  exhibit 
special  characters  which  show  that  some  form  of  secretion  is  want- 
ing or  perverted. 

§  1.  Disordered  Bowels. — This  first  subdivision  must  include  by 
far  the  larger  number  of  cases ;  we  are  yet  far  too  ignorant  of  the 
special  actions  going  on  to  attempt  to  classify  them  more  accurately, 
and  the  only  reason  for  their  enumeration  is,  that  the  question  of 
classification  leads  to  investigating  symptoms  more  closely,  and 
thinking  more  clearly  of  the  morbid  actions  presented,  and  there- 
fore tends  to  a  more  judicious  selection  of  remedies. 

a.  In  childhood  we  often  find  a  condition  of  mal-nutrition  and 
anaemia,  with  a  ravenous  appetite  and  unhealthy  secretions,  when 
the  rectum  is  very  generally  loaded  with  ascarides:  in  such  cases 
it  used  to  be  imagined  that  the  worms  were  the  cause  of  all  the 
symptoms ;  it  seems  more  probable  that  the  true  explanation  is  to 
be  found  in  the  faulty  secretion  of  the  canal  affording  a  nisus  for 
the  development  of  the  parasite.  Whether  the  condition  of  the 
bowels  be  primary  or  secondary,  it  is  of  no  importance  to  inquire, 
because  it  is  invariably  accompanied  by  symptoms  of  more  general 
disorder,  and  these  demand  our  attention  and  care  quite  as  much 


328  DISEASES   OF  TIIE   INTESTINAL   CANAL. 

as  the  local  ailment.  It  is  also  quite  a  matter  of  accident  whether 
there  be  diarrhoea  or  constipation  at  the  time  of  examination,  be- 
cause as  a  general  rule  we  shall  find  that  neither  condition  is  per- 
sistent, but  that  the  child  has  been  subject  to  one  or  other  for  some 
time.  The  chief  difficulty  presented  is  the  close  analogy  of  such 
cases  to  those  of  mesenteric  disease:  so  little  is  known  of  the  scro- 
fulous element  that  we  can  scarcely  form  any  correct  diagnosis  until 
the  dry  shrivelled  skin  and  prominent  belly  leave  us  in  no  doubt; 
and  our  prognosis  must  be  always  guarded  when  any  symptoms  of 
scrofula  have  been  marked  in  the  child's  history. 

b.  In  other  cases  the  evacuations  present  appearances  more  or 
less  definitely  indicating  the  secretion  that  is  at  fault.  _  Thus  we 
have  the  "chopped  spinach"  appearance  of  the  stools  in  infancy, 
their  excessively  dark  colour,  or  the  opposite,  in  adult  life,  each 
pointing  out  that  the  biliary  secretion  is  that  to  which  attention 
should  be  paid:  in  other  instances,  undigested  aliment,  mixed  with 
fteculent  matter,  shows  that  the  gastric  juice  is  defective  in  quality, 
or  insufficient  in  quantity:  the  lodgement  of  dark,  offensive  faeces, 
again,  which  are  got  rid  of  by  nature  or  art,  from  time  to  time, 
rather  leads  to  the  belief  that  the  secretion  in  the  bowels  themselves 
is  defective. 

We  must  not  forget  in  this  enumeration  the  frothy,  yeast-like 
motions  which  are  occasionally  passed,  and  seem  to  show  that  fer- 
mentation has  taken  the  place  of  intestinal  digestion,  just  as  we 
found  the  same  circumstance  when  occurring  in  the  stomach  indi- 
cated by  vomiting  of  a  similar  character.  Nor  must  we  omit  that 
rare  condition  which  has  been,  with  some  reason,  attributed  to  dis- 
ease of  the  pancreas — viz.,  the  passage  of  fatty  matter  in  a  liquid 
state  along  with  the  feces,  which  floats  on  the  surface  of  water,  and 
consolidates  with  cold. 

Much  may  undoubtedly  be  learned  from  an  inspection  of  the  stools;  and  no 
careful  practitioner  will  omit  it  when  treating  a  case  in  which  there  is  a  possibility 
of  disease  of  the  abdominal  viscera.  In  almost  any  of  the  cases  just  mentioned, 
the  first  complaint  is  very  likely  to  be  of  a  transient  diarrhoea,  in  consequence  of 
the  irritation  which  these  matters  excite;  or,  passing  by  the  repeated  alternations 
of  constipation,  the  patient  may  only  speak  of  being  subject  to  diarrhoea,  and,  until 
the  excreta  be  seen,  we  may  be  ignorant  of  his  real  state.  It  seems  pretty  cer- 
tain that,  when  we  find  irregular  action  lasting  for  a  considerable  period,  we  may 
regard  it  as  due  to  a  fault  in  some  of  those  secretions  which  serve  to  prepare  the 
alimentary  substances  for  the  uses  of  the  economy,  and  our  chief  object  must  be 
to  detect  and  correct  that  fault:  in  the  majority  of  instances  this  can  only  be  done 
by  seeing  the  character  of  the  stools. 

§  2.  Tympanites. — The  presence  of  flatus  in  the  abdomen,  as  it 
always  results  from  any  disorder  of  the  bowels,  would  not  deserve 
mention  except  that  cases  are  occasionally  Seen  in  which  this  is  the 
principal  ailment.  We  search  in  vain  for  other  direct  evidence  of 
faulty  secretion ;  and,  except  that  the  bowels  are  usually  sluggish, 
and  the  patient  suffers  much  inconvenience  from  the  distention,  the 
circumstance  might  be  disregarded  altogether.     The  cases  do  not 


TYMPANITES.  329 

present  any  great  difficulty  in  diagnosis,  but  they  are  very  trouble- 
some to  manage:  the  only  point  which  we  have  to  ascertain  with 
care  is,  that  the  enlargement  of  the  abdomen  is  not  produced  by 
some  other  cause,  while  the  resonance  is  no  more  than  that  usually 
heard  on  percussing  over  the  intestines  when  thus  pushed  forward. 
Such  a  combination  of  distention  and  resonance,  for  example,  may 
be  observed  when  a  small  quantity  of  fluid  exists  low  down  in  the 
peritoneum ;  and  mistakes  of  this  kind  have  been  made  when  the 
distention  was  produced  by  enlargement  of  some  of  the  pelvic 
viscera ;  e.  </.,  the  uterus  or  the  bladder. 

A  tympanitic  condition  exists,  very  generally,  in  peritonitis,  both  in  its  acute  and 
chronic  forms ;  it  is  also  very  common  in  bowel-fever.  Each  of  these  diseases 
presents  symptoms  which  ought  not  to  be  overlooked  and  cannot  be  misunderstood: 
in  them  the  distention  is  not  caused  so  much  by  any  abnormal  condition  of  the 
secretions  as  by  the  loss  of  muscular  power,  which  allows  the  flatus  to  accumu- 
late. It  is  possible  that  a  similar  condition  may  have  to  do  with  the  production  of 
genuine  tympanites,  and  that  it  may  be  in  part  due  to  muscular  paralysis:  it  seems, 
however,  scarcely  possible  that  it  should  exist  to  any  gTeat  extent  from  this  cause 
alone,  and  I  think  there  can  be  no  doubt,  whether  any  other  disorder  of  the  bowel 
mark  its  presence  or  not,  that  faulty  secretion  is  an  essential  element.  The  dia- 
gnosis of  this  condition  of  things  rests,  indeed,  rather  on  negative,  than  positive 
evidence;  the  tympanitic  distention  may  be  proved,  but,  in  the  further  analysis  of 
the  case,  we  have  to  make  out  rather  the  absence  of  actual  disease  than  the  pre- 
sence of  any  morbid  condition  of  which  pathology  can  lay  hold:  hence,  it  is  one 
in  which  we  are  very  liable  to  error,  and  one  which  increasing  knowledge  may  at 
some  future  period  enable  us  to  discard  altogether  from  our  nosology.  The  diffi- 
culties are  certainly  not  lessened  by  the  circumstance  that  it  is  very  often  associ- 
ated with  hysteria. 


330 


CHAPTER  XXVIII. 

DISEASES    OF   THE   PERITONEUM. 

§  1,  Acute  Peritonitis — (a)  Traumatic — (b)  Puerperal — (<?)  Idio- 
pathic— (d)  Partial — §  2,  Chronic  Peritonitis — Simple — Tuber- 
cular or  Cancerous — §  3,  Blorbid  Growths  in  the  Peritoneum. 

In  speaking  in  general  terms  of  the  diseases  of  the  peritoneum 
we  might  include  all  those  occasions  on  which  it  bears  a  part  in 
disease  of  the  viscera  which  it  encloses.  It  seems  better,  however, 
to  limit  our  attention  to  those  conditions  in  which  the  membrane 
is  principally  or  alone  involved — the  acute  and  chronic  forms  of 
inflammation;  along  with  the  latter  the  non-inflammatory  exuda- 
tions must  be  noticed,  and  the  occasional  association  of  ascites:  a 
few  remarks  must  also  be  made  upon  those  tumours  which,  as  they 
are  unconnected  with  any  particular  organ,  will  not  find  a  place  in 
the  succeeding  pages  of  this  volume. 

§  1.  Acute  Peritonitis. — The  extent  of  the  serous  membrane 
lining  the  abdominal  cavity  is  such  that,  when  the  inflammation 
pervades  its  whole  surface,  the  symptoms  are  more  severe  than  are 
met  with  in  any  other  organ  of  the  body ;  and  at  the  same  time 
its  folds  are  so  numerous  that  the  spread  of  the  inflammatory  action 
is  liable  to  be  checked  by  the  adhesion  of  two  contiguous  portions 
in  a  way  that  is  not  met  with  in  other  serous  membranes.  We 
might,  therefore,  divide  the  cases  into  general  and  partial  peritoni- 
tis ;  but  for  the  purposes  of  diagnosis  the  former  must  be  again 
subdivided,  as  the  history,  the  progress,  and  the  symptoms  are  so 
dissimilar  in  the  different  forms,  that  they  might  almost  be  regarded 
as  distinct  diseases. 

a.  Traumatic  peritonitis. — I  can  find  no  better  name  for  that 
which  arises  suddenly,  after  rupture  of  some  organ  and  escape  of 
its  contents  into  the  abdomen ;  and  this  whether  occurring  from  ex- 
ternal violence  or  not:  it  differs  in  no  respect  from  the  inflamma- 
tion excited  by  a  penetrating  wound  of  the  abdomen.  It  generally 
results  from  previous  thinning  of  the  membrane  by  disease:  but  on 
this  point  the  history  of  the  case  is  perhaps  silent.  Sometimes, 
indeed,  we  may  learn  that  the  individual  has  had  hsematemesis,  or 
other  symptoms  of  ulceration  of  the  stomach,  or  the  persistence  of 
diarrhoea  in  phthisis,  or  in  convalescence  from  fever,  points  to  a 
similar  condition  of  the  small  intestine.  Without  any  previous 
warning,  the  patient  is  suddenly  seized  with  severe  pain  on  making 
some  unusual  strain;  we  find  great  tenderness  and  tension  over  the 
abdomen,  extreme  prostration,  probably  sickness  and  painful  efforts 


DISEASES    OF    THE   PERITONEUM.  331 

at  vomiting;  the  pulse  is  feeble,  quick,  and  labouring;  the  skin  be- 
comes cold,  and  covered  with  perspiration ;  and  he  sinks  rapidly. 
The  state  of  collapse  resembles  cholera,  but  there  is  no  evacuation 
from  the  bowels;  the  mental  faculties  are  clear,  and  therefore  nar- 
cotic poisoning  is  excluded,  while  both  suppositions  are  opposed  by 
the  existence  of  extreme  pain  all  over  the  abdomen;  and,  on  the 
other  hand,  there  is  no  irritation  about  the  mouth  and  fauces  to 
suggest  the  possibility  of  irritant  poisoning. 

Perhaps  we  may  obtain  a  history  of  a  blow  or  a  fall  which  may 
have  ruptured  the  stomach  or  the  liver,  &c. ;  death  has  been  even 
known  to  result  from  a  blow  on  the  stomach  without  rupture,  in 
which,  from  its  suddenness,  peritonitis  can  have  had  no  share. 
Occasionally  we  meet  with  suppression  of  urine ;  and  when  the  ca- 
theter is  introduced,  only  a  few  drops  of  blood  are  evacuated,  and 
then  it  is  probable  that  the  bladder  has  been  ruptured  by  the  acci- 
dent. 

The  symptoms  are  occasionally  not  quite  so  severe,  because  the 
effusion  of  the  visceral  contents  has  been,  to  a  certain  extent,  limit- 
ed by  adhesions,  and  then  the  attack  cannot  be  distinguished  from 
idiopathic  general,  or  partial  peritonitis. 

b.  Puerperal  peritonitis  presents  the  same  features  as  the  third 
form,  of  which  we  have  yet  to  speak;  it  is  only  distinguished  by 
its  history  in  connexion  with  childbirth,  and  demands  separate  no- 
tice, from  the  peculiar  condition  of  the  blood  with  which  it  is  asso- 
ciated, and  the  different  treatment  which  it  consequently  demands. 

On  this  point  practical  medicine  has  made  great  advances  in  late  years:  inflam- 
mation, which  post-mortem  examination  reveals  to  have  been  of  great  extent  and 
intensity,  does  not  of  necessity  suggest  the  use  of  the  lancet;  the  correlative  symp- 
toms must  he  taken  into  account,  both  with  reference  to  the  previous  exhaustion 
of  labour  and  the  special  characteristics  of  the  disease  in  the  individual  case.  It 
seems  highly  probable  that  two  forms  of  puerperal  peritonitis  exist,  of  which  the 
one  corresponds  to  ordinary  inflammation,  being  only  modified  by  the  previous 
exhaustion  of  a  labour  perhaps  unusually  severe;  the  other,  by  far  the  most_ com- 
mon, is  the  result  of  suppurative  changes  in  the  blood,  and  presents  analogies  to 
erysipelas.  It  is  worth  remembering  that,  as  erysipelas  and  its  allied  diseases 
occasionally  put  on  an  epidemic  character,  so  also  does  puerperal _ fever ;_  and  its 
frequent  occurrence  at  any  given  time  would  tend  to  confirm  a  diagnosis  drawn 
from  the  character  of  the  symptoms,  which  are  asthenic,  and  approximate  those 
of  suppurative  fever.  The  pulse  is  very  frequent  and  feeble,  there  is  often  diar- 
rhoea, the  tongue  is  not  much  coated,  and  more  frequently  raw  and  chapped,  and 
even  an  aphthous  state  of  the  mouth  and  of  the  anus  are  recorded.  The  question 
of  its  propagation  by  contagion,  which  is  now  pretty  generally  acknowledged,  may 
also  serve  to  guide  our  opinion,  because,  if  in  the  hands  of  the  same  practitioner 
another  case  of  puerperal  fever  have  recently  occurred,  there  is  good  ground  for 
suspecting  that,  through  some  means  or  other,  the  same  blood-poison  has  been 
introduced. 

In  a  few  cases  the  inflammation  becomes  limited  to  the  uterus 
and  its  appendages,  when  the  disease  does  not  differ  from  cases  oc- 
curring in  the  non-parturient  state,  which  we  class  as  local  peri- 
tonitis. 

c.  Idiopathic  peritonitis  will  give  a  very  different  history,  accord- 


832  DISEASES    OF    THE    PERITONEUM. 

in"1  to  the  circumstances  in  which  it  occurs,  and  the  causes  on 
which  it  depends.  It  may  arise  in  a  stout,  healthy  person  from  ex- 
posure, or  from  injury;  or,  in  the  very  opposite  condition,  in  one 
■worn  by  fever  or  phthisis,  when  excited  by  extensive  ulceration  of 
the  coats  of  the  bowel,  even  when  no  rupture  occurs.  Its  close 
connexion  with  enteritis  has  been  already  mentioned;  it  is  similarly 
allied  to  inflammation  on  the  upper  side  of  the  diaphragm,  some- 
times preceding,  sometimes  following  diaphragmatic  pleurisy;  it  is 
often  met  with  in  uterine  derangements  apart  from  pregnancy, 
although  then  it  is  more  generally  local  and  limited. 

The  best  examples  of  its  pure  type  will  be  found  in  cases  which 
are  believed  to  have  been  excited  by  exposure,  when  at  least  no 
other  cause  can  be  assigned,  or  those  which  have  followed  some  me- 
chanical violence  without  rupture  of  any  viscus.  The  leading 
symptom  is  pain  and  tenderness,  which  we  know  to  be  characteris- 
tic of  inflammation  of  all  serous  membranes.  Enough  has  been 
already  said  to  show  the  necessity  for  caution  in  taking  this  symp- 
tom as  our  chief  indication ;  but  with  due  care  we  cannot  be  de- 
ceived in  a  case  of  general  peritonitis.  There  is  not  only  the 
complaint  of  pain,  but  the  position  of  pain ;  the  patient  shrinks 
from  pressure,  and  we  learn  more  from  the  expression  of  pain 
by  feature  than  by  exclamation;  but  the  evidence  is  still  more 
trustworthy  which  is  obtained  from  the  knees  being  drawn  up,  the 
motionless  diaphragm,  and  the  fixedness  of  the  body.  We  must 
not  rudely  press  on  the  abdomen ;  but  its  distended  outline  and  its 
tympanitic  tension  and  tenderness  show  clearly  that  inflammation 
is  going  on  beneath  the  surface.  Besides  this,  there  is  the  pre- 
sence of  fever,  a  quick  pulse,  a  coated  tongue,  and  a  hot  skin; 
often  sickness,  sometimes  dysuria,  and,  if  the  mucous  membrane  be 
affected,  the  bowels  may  be  relaxed ;  but  more  commonly  there  is 
constipation  from  a  sort  of  paralysis  of  the  muscular  fibre,  which 
also  produces  the  tympanitic  distention:  even  if  the  stools  be  wa- 
tery, there  is  always  a  certain  impediment  to  the  free  action  of  the 
bowels. 

Such  may  be  regarded  perhaps  as  an  extreme  case,  and  it  may  be  alleged 
that  there  are  others  of  a  much  milder  form:  at  all  events,  in  common  parlance 
many  cases  are  spoken  of  as  "inflammation"  which  do  not  come  up  to  this  type. 
The  majority  of  these,  when  inflammation  really  exists,  belong  to  the  next  divi- 
sion; in  a  few  perhaps,  from  constitutional  apathy,  the  evideuce  of  suffering  is  less 
distinct;  but  in  a  large  number  I  think  we  must  admit  that  errors  in  diagnosis 
are  committed  from  taking  a  contracted  view  of  the  symptoms,  being  contented  with 
the  observation  of  one  or  two,  while  the  rest  are  forgotten  or  overlooked.  Genuine 
cases  of  idiopathic  peritonitis  are  certainly  rare;  and  when  there  has  been  no  in- 
jury, when  there  is  no  evidence  of  antecedent  affection  of  the  intestines,  and  the 
case  does  not  belong  to  the  puerperal  form,  the  practitioner  ought  not  hastily  to 
come  to  the  conclusion  that  he  has  so  formidable  a  disease  to  deal  with;  at  the 
same  time,  when  the  patient  is  in  fair  health,  the  error  in  over-activity  is  perhaps 
the  least  dangerous. 

ch  Partial  peritonitis. — During  the  incursion  of  an  ordinary  at- 
tack of  peritonitis,  the  pain  is  frequently  confined  to  one  spot, 


PARTIAL   PERITONITIS.  333 

where  it  may  linger  for  a  considerable  period ;  and  this  is  very 
generally  the  lower  part  of  the  abdomen:  for  a  time  the^ pulse  is 
not  particularly  accelerated.  These  are  cases  in  which  it  is  due  to 
some  local  cause,  and  from  thence  it  may  spread  to  the  whole  mem- 
brane, or  may  remain  fixed  at  the  spot  where  it  originated,  putting 
on  a  subacute  type,  and  preserving  a  local  character.  Partial  peri- 
tonitis is  no  doubt  very  often  overlooked,  and  leaves  traces  of  its 
existence  in  bands  of  adhesion,  when  no  account  of  its  history  ia 
obtained.  The  chief  indication  upon  which  we  must  rely  is  the 
existence  of  tenderness  on  pressure,  accompanied  by  slight  pyrexia. 
This  serves  to  distinguish  it  from  colic,  and  from  the  passage  of  a 
calculus,  whether  biliary  or  renal,  the  latter  more  especially  imi- 
tating it  in  site:  in  them  the  pain  greatly  exceeds  the  tenderness, 
and,  indeed,  is  often  relieved  by  pressure,  while  the  pulse  is  slower 
than  natural — slower  at  all  events  than  we  could  imagine  possible 
if  the  same  amount  of  pain  were  due  to  inflammatory  action. 

Partial  peritonitis  may  be  excited  by  ulceration  of  the  bowels 
which  does  not  proceed  to  an  extreme  degree,  and  has  a  conserva- 
tive tendency  to  prevent  perforation ;  this  constantly  happens  in 
phthisis,  when  it  may  pass  altogether  unobserved.  It  is  very  often 
produced  by  some  unusual  irritation  within  the  bowel,  such,  for  ex- 
ample, as  the  lodgement  of  undigested  substances  about  the  caecum ; 
and  these  cases  very  frequently  pass  into  suppuration.  Sometimes 
the  puerperal  inflammation  is  thus  limited  to  the  neighbourhood  of 
the  uterus,  and  pus  may  be  ultimately  discharged  by  the  rectum  or 
vagina,  or  the  uterus  and  its  appendages  may  become  matted  to- 
gether and  adherent  to  surrounding  parts.  It  is  not  uncommon  in 
women  who  are  subject  to  irregular  menstruation,  especially  when 
attended  by  uterine  irritation ;  but  with  them  the  disease  seldom 
terminates  in  suppuration. 

When  the  inflammation  is  of  any  notable  extent,  or  when  the 
rest  of  the  membrane  is  in  any  degree  irritated  by  the  persistence  of 
the  local  action,  we  generally  find  some  expression  of  tenderness 
in  the  posture  of  the  patient  besides  what  is  observed  on  pressure ; 
dysuria,  too,  is  a  very  common  symptom  in  those  attacks  which  are 
seated  in  the  pelvis.  As  the  disease  advances,  considerable^ infiltra- 
tion of  the  surrounding  tissues  takes  place,  and  local  swelling  may 
be  observed,  at  first  deep-seated,  but  very  soon  involving  the  pa- 
rietes,  which  become  hard  and  painful  over  the  seat  of  inflamma- 
tion, in  preparation,  as  it  were,  for  the  occurrence  of  suppuration. 

In  enteritis  we  have  a  set  of  symptoms  which,  without  reaching  the  same  inten- 
sity as  general  peritonitis,  have  a  very  similar  character  to  those  of  partial  peri- 
tonitis, only  with  more  decided  constipation  and  more  constant  vomiting;  and  it  is 
really  of  no  consequence  whether  we  can  discriminate  between  the  two,  or  can 
say,  when  both  exist  together,  which  is  the  more  prominent. 

In  fever,  again,  it  is  of  importance  that  the  existence  of  the  blood-disease  should 
not  be  lost  sight  of  in  regard  to  treatment,  and  if  in  the  early  stage  there  be  pain 
of  the  bowels,  with  tympanites  and  tenderness,  the  diagnosis  requires  care.  Two 
facts  we  may  remember,  first,  that  in  fever  the  symptoms  which  are  called  febrile, 


334  DISEASES  OF  THE  PERITONEUM. 

the  hot  skin,  quick  pulse,  &c,  preponderate,  and  are  out  of  proportion  to  the  local 
signs  of  tenderness;  second,  thai  die  bowels  are  relaxed,  with  borborygmi  or  me- 
ismua  in  fever,  while  such  a  circumstance  is  much  less  common  in  peritonitis, 
and  is  always  attended  with  aggravation  of  the  pain:  fever  spots  on  the  abdomen 
I  of  course  remove  any  doubt.  In  advanced  fever  genuine  peritonitis  very 
often  comes  on  either  with  or  without  rupture  of  the  intestine:  in  its  treatment  re- 
gard must  be  had  to  the  previous  existence  of  blood-disease. 

§  2.  Chronic  Peritonitis. — Two  forms  of  this  disease  are  recog- 
nised, a.  The  acute  attack  runs  on  into  a  chronic  form.  b.  An 
insidious  disease  arises  without  acute  symptoms,  which  is  most  com- 
monly associated  with  a  tubercular  or  a  cancerous  diathesis. 

a.  The  suppurative  stage  of  partial  peritonitis,  as  it  may  continue 
for  a  lengthened  period,  might  be  regarded  as  an  instance  of  chronic 
disease:  the  condition,  however,  which  we  wish  to  distinguish  by 
this  name,  is  one  in  which  the  acute  symptoms  have  entirely  sub- 
sided. The  patient  perhaps  continues  liable  to  uneasiness  in  some 
particular  part  of  the  abdomen,  which,  on  examination,  is  found  to 
be  harder  than  natural;  occasional  exacerbations  occur,  and  after 
a  Ion"-  interval,  during:  one  of  these  accessions  of  fever,  the  case 
terminates  in  suppuration,  the  matter  either  finding  vent  outwards, 
or  exciting  general  peritonitis  and  blood-poisoning.  In  other  cases 
the  inflammation  has  been  more  general,  the  bowels  have  contracted 
adhesions,  and  the  patient  is  subject  to  constant  irritation,  both  in 
the  interior  of  the  canal  and  in  the  peritoneum  itself;  there  is  al- 
most constant  tenderness,  and  at  length  suppurative  inflammation 
supervenes,  or  ascites  is  developed,  or  the  action  of  the  bowels  is 
so  seriously  interrupted  that  the  patient  sinks  from  mere  inanition. 

If  the  history  of  such  cases  be  sufficiently  distinct,  the  difficulty 
of  diagnosis  is  not  great;  but  there  is  generally  little  trustworthy 
information  to  be  obtained  beyond  the  fact  that  there  has  been  at 
no  very  great  distance  of  time  a  severe  illness  with  much  pain  in 
the  abdomen:  and  when  with  this  there  is  abiding  tenderness,  with 
some  acceleration  of  pulse,  and  some  tendency  to  constipation; 
when  the  general  outline  of  the  abdomen  is  full  and  rather  tense 
and  tympanitic;  if  there  be,  on  the  one  hand,  hardness  felt  in  a 
particular  spot,  or  on  the  other,  serous  effusion  found  in  the  cavity 
of  the  peritoneum, — the  diagnosis  may  be  regarded  as  pretty  cer- 
tain. The  greatest  chance  of  error  is  when  hardness  is  felt,  be- 
cause such  a  circumstance  might  be  caused  by  frecal  accumulation. 
But  when  neither  hardness  is  felt  nor  fluid  detected,  there  will  be  a 
considerable  resemblance  to  cases  of  ulceration  of  the  bowels ;  in 
them,  however,  diarrhoea  is  generally  present,  while  in  chronic  peri- 
tonitis the  bowels  are  irregular,  and  rather  incline  to  constipation. 

In  speaking  of  ascites,  reference  was  made  to  its  occasionally  resulting  from 
chronic  peritonitis;  but  it  was  then  observed  that  really  this  is  not  by  any  means 
its  common  cause.  It  is  true  that  along  with  the  thickened  capsule  of  the  liver 
there  is  often  found  a  certain  thickening  of  the  peritoneal  membrane,  and  possibly 
this  condition  may  have  a  clinical  history  of  inflammation  which  we  have  over- 
looked; but,  except  there  be  the  evidence  of  adhesions,  it  seems  to  be  a  misap- 


CHRONIC    PERITONITIS.  335 

propriation  of  language  to  call  that  pathological  state  by  a  name  which  implies 
that  a  disease  has  occurred  of  the  existence  of  which  during  life  we  haveno  proof 
whatever.  The  pathology  of  chronic  peritonitis  is  always  associated  with  adhe- 
sions; and  for  this  reason  the  ascites  which  occasionally  supervenes  very  generally 
presents  characters  of  much  interest,  which  tend  more  or  less  to  obscure  its  dia- 
gnosis. The  relations  of  the  fluid  to  the  intestine  are  changed,  they  no  longer 
obey  the  laws  of  gravitation,  but  either  a  portion  of  intestine,  which  is  specifically 
lighter,  is  tied  down,  so  that  it  cannot  rise  to  the  surface  of  the  fluid,  or  the  whole 
of  the  fluid  is  so  hemmed  in  by  adhesions  that  it  cannot  reach  the  most  depending 
situation,  although  itself  specifically  heavier.  In  using  the  term  ascites  in  this 
way  it  must  be  understood  that  such  an  accumulation  of  fluid  is  meant  as  really 
becomes  of  itself  a  source  of  inconvenience  or  of  danger  to  the  patient :  for,  though 
the  peritoneal  membrane  in  its  inflammations  contrasts  very  remarkably  with  the 
pleura  in  regard  to  effusion,  yet  a  small  quantity  of  turbid  serum,  mixed  with 
flakes  of  lymph,  or  of  fluid  closely  resembling  pus,  may  be  found  in  most  cases 
both  of  acute  and  chronic  peritonitis. 

b.  In  the  second  form  the  symptoms  come  on  so  insidiously  that 
there  is   generally  no  complaint  of  illness  till  the  disease  is  fully 
developed;  and  were  it  otherwise,  the  indications  of  what  is  going 
on  are  not  sufficiently  distinct  to  be  relied  on:     When  the  patient 
is  first  seen  there  is  generally  a  persistent  acceleration  of  the  pulse, 
with  a  certain  amount   of   emaciation   and  loss  of   strength;  the 
"bowels  act  irregularly,  and  the  motions  are  often  unhealthy  and 
offensive:  sometimes,  however,  this  symptom  is  wanting:  he  com- 
plains of  deep-seated  pain  or  uneasiness,  with  a  feeling  of  tension 
or  fulness  of  the  abdomen.     Placed  on  his  back  in  bed,  the  abdo- 
men is  still  full ;  and  though  the  extreme  tension  and  tenderness  of 
acute  peritonitis  be  wanting,  yet  pressure  causes  uneasiness,  and 
the  parietes  have  a  feeling  of  hardness  which  is  extremely  different 
from  the  elasticity  of  health:  when  the  disease  is  much  advanced, 
the  fulness  of  the  belly  contrasts  very  strikingly  with  the  emacia- 
tion over  the  ribs  and  pelvis.    This  fulness,  it  must  be  remembered, 
is  not  like  that  produced  by  ascites,  for  it  scarcely  exceeds  in  the 
erect  posture  that  which  is  constantly  found  in  health,  and  it  is 
only  when  the  patient  is  lying  down  that  the  difference  strikes  the 
eye :  any  doubt  as  to  whether  it  be  dependent  on  an  accumulation 
of  fluid  is  immediately  set  at  rest  by  percussion ;  the  abdomen  is 
universally  resonant,  and  any  indications  of  fluid  are  scanty  and 
limited.     The  pathological  condition  in  these  cases  sufficiently  ac- 
counts for  the  symptoms  to  which  we  have  just  referred.    The  peri- 
toneal membrane  is  studded  with  morbid  growths,  tubercular,  scro- 
fulous, or  cancerous,  and  the  intestines  are  glued  together  by  adhe- 
sions; they  are  consequently  distended  with  gas  which  they  are 
unable  to  expel,  and  they  cannot  glide  on  each  other  in  change  of 
position,  so  that  the  parietes  do  not  retract  as  the  patient  lies  on 
his  back. 

In  further  attempting  to  analyze  these  forms  of  peritonitis,  we  may  be  guided 
by  the  following  general  considerations.  The  tubercular  occurs  especially  in  the 
period  of  youth,  it  is  associated  with  a  particular  diathesis,  and,  like  tubercular 
attacks  in  general,  is  apt  to  supervene  upon  measles  or  other  diseases  of  infancy, 
as  well  as  upon  exposure,  bad  living,  &c.     It  is  attended  with  emaciation,  quick 


33G  DISEASES   OF   THE   PERITONEUM. 

pulse,  irregular  bowels,  and  the  signs  of  hectic  rather  than  of  inflammatory  fever: 
the  skin  of  the  abdomen  has  a  remarkably  harsh,  dry  feeling,  and  some  reliance 
mav  be  placed  upon  a  sensation  as  if  the  muscles  could  be  moved  over  the  hard- 
I  peritoneum  beneath.  But,  however  distinct  in  its  full  development,  its  ear- 
lier stages  cau  only  be  guessed  at. 

The  cancerous  form,  again,  occurs  chiefly  after  middle  age.  Perhaps  the  face 
has  acquired  the  sallow  hue  of  malignant  disease,  and  there  is  generally  consider- 
able emaciation:  with  care,  generally  some  indication  of  fluid  is  found.  The  ten- 
derness is  not  so  great  as  in  other  cases,  and  the  distinctive  character  of  the  dis- 
ease may  sometimes  be  made  out,  when,  by  gentle  and  yet  firm  pressure,  the 
rounded  nodules  of  cancer  are  felt  under  the  muscles  of  the  parietes. 

§  3.  Morbid  Groivths  in  the  Cavity  of  the  Peritoneum. — In  the 
two  forms  of  chronic  peritonitis  just  detailed,  the  peritoneum  itself 
is  the  seat  of  the  tubercle  and  the  cancer:  we  have  now  to  speak 
of  the  same  morbid  material  when  deposited  in  the  glands,  the 
mesentery,  and  the  omentum.  Early  diagnosis  seems  almost  im- 
possible :  until  the  tumour  has  become  sensible  to  the  touch,  or  has 
excited  inflammation,  we  are  in  great  measure  ignorant  of  its  exist- 
ence ;  we  have  not  even  the  indication  of  uneasiness  or  tenderness 
to  guide  us,  before  the  appearance  of  the  concomitant  inflammation. 
It  is  true  that  they  occasionally  interfere  with  or  press  upon,  some 
nervous  trunk,  and  anomalous  neuralgic  pains  may  be  complained 
of  in  the  scrotum  or  in  the  leg;  but  this  can  hardly  rank  as  a 
symptom. 

The  patient  presents  a  cachectic  and  emaciated  appearance,  while 
his  appetite  continues  good,  and  the  process  of  digestion  seems  little 
interfered  with;  the  pulse  is  more  apt  to  be  accelerated  when  the 
disease  is  scrofulous  than  when  malignant,  and  is  always  small  and 
weak ;  the  stools  are  very  often  unhealthy,  especially  when  the 
morbid  deposit  is  situated  in  the  mesentery;  but  no  distinct  charac- 
ters can  be  assigned  to  them.  The  complaint  may  be  simply  of 
weakness  and  emaciation,  or  of  sensation  of  uneasiness  or  pain  in 
the  abdomen,  or  of  anomalous  neuralgia.  We  search  for  evidence 
of  the  existence  of  any  wasting  disease,  and  by  the  process  of  ex- 
clusion we  are  convinced  it  must  be  situated  in  the  abdomen ;  in 
scrofulous  children  we  suspect  the  presence  of  tabes  mesenterica; 
in  adults  we  may  be  quite  unable  to  form  an  opinion  of  its  nature. 
After  a  time  the  belly  is  either  tumid  and  hard,  with  nodules  of 
greater  or  less  size,  perceptible  on  thrusting  the  points  of  the  fin- 
gers deeply  among  the  bowels;  or  it  is  shrivelled  and  shrunken, 
and  hard  masses  are  readily  to  be  felt  quite  superficially.  In  the 
former  there  is  probably  some  peritoneal  inflammation  and  effusion, 
and  it  requires  some  care  in  making  the  examination  to  discrimi- 
nate enlargements  of  the  liver  or  spleen  in  the  altered  positions 
they  sometimes  assume.  In  the  latter  there  may  be  some  difficulty 
in  distinguishing  morbid  growths  from  masses  of  hardened  fieces. 

Greater  mistakes,  however,  are  much  more  likely  to  be  made  on 
the  other  side,  when  complaints  of  what  seem  to  be  only  functional 
derangements  of  the  stomach  and  bowels  lead  us  away  from  con- 


MORBID   GROWTHS.  337 

sidering  the  possibility  of  such  a  serious  malady ;  or  when,  if  the 
idea  be  suggested,  and  an  examination  instituted,  the  discovery  of 
nothing  to  confirm  the  suspicion  throws  us  back  again  on  the  idea 
of  functional  disturbance,  till  progressive  emaciation  and  final 
exhaustion  of  the  powers  of  life  prove  that  there  was  something 
real  in  the  hypothesis. 

The  largest  growths  of  the  kind  referred  to  are  those  which  take 
place  in  the  omentum  when  occupied  by  encephaloid,  and  especially 
colloid  cancer:  they  are  more  likely  to  be  mistaken  for  enlarge- 
ment of  the  liver  or  spleen  than  any  others.  Next  in  size  are 
encephaloid  masses  in  the  mesentery:  those  which  are  most  apt  to 
escape  detection  are  such  as  take  their  rise  in  the  glands  close  to 
the  spine.  Mesenteric  disease  tends  more  than  any  other  to  excite 
inflammation  and  exudation  into  the  peritoneum.  It  seems  scarcely 
necessary  to  add  that  scrofulous  deposits  are  more  common  during 
the  period  of  growth,  and  that  malignant  diseases  usually  occur 
after  middle  life. 


22 


338 


CHAPTER  XXIX. 

DISEASES    OF   THE    LIVER,    SPLEEN,    AND    PANCREAS. 

Div.  I. — Diseases  of  the  Liver — Obscurity  of  Symptoms. — §  1, 
Inflammation — Congestion — Abscess — §  2,  Enlargement — Non- 
malignant— from  Morbid  G-roiuth — §  3,  Cirrhosis — §  4,  Jaundice 
— Functional  Disorder — §  5,  Grail-stones. 

Div.  II. — Diseases  of  the  Spleen — Change  of  Structure — Enlarge- 
ment. 

Div.  III. — Diseases  of  the  Pancreas — Seirrhus. 

Div.  I. — Diseases  of  the  Liver. 

This  subject  is  as  yet  beset  with  difficulties:  we  are  only  now  beginning  to  learn 
from  pathological  research  the  meaning  of  terms  which  have  been  in  common  use, 
such  as  "nutmeg-liver,"  "cirrhosis,"  &c;  we  have  but  little  knowledge  of  what 
changes  are  due  to  inflammation,  what  to  depraved  nutrition;  and  therefore  can- 
not speak  with  certainty  of  the  indications  which  might  show  that  such  a  change 
was  going  forward;  and,  as  a- necessary  consequence,  we  are  in  great  ignorance 
regarding  its  functional  disorders,  because  we  cannot  discriminate  the  symptoms 
which  portend  the  commencement  of  some  grave  malady  from  those  of  transient 
disorder. 

Another  difficulty  meets  us  on  the  very  threshold  of  our  inquiry  into  the  dia- 
gnosis of  its  diseases,  viz.,  that  it  is  exceedingly  difficult  to  separate  the  symptoms 
due  to  disorder  of  the  liver  from  those  of  other  portions  of  the  digestive  apparatus. 
Covered  in  great  measure  by  the  ribs,  there  are  no  auscultatory  phenomena  to  aid 
our  investigation,  except  on  the  single  question  of  its  size;  and  placed  at  the  very 
summit  of  the  intestinal  canal,  and  yet  below  the  valve  of  the  pylorus,  the  state  of 
its  secretion  cannot  be  accurately  ascertained,  either  by  examining  the  faeces,  or 
by  exciting  the  act  of  vomiting.  Half  the  minor  ailments  of  life  are  attributed  by 
persons  unacquainted  with  medicine  to  "biliousness,"  while  the  accomplished 
physician  is  almost  unable  to  say  what  it  is  to  be  "bilious."  Let  us  hope  that  the 
progress  of  analytical  chemistry  may  ere  long  throw  some  light  upon  this  obscu- 
rity, and  discover  some  ready  means  to  indicate  at  least  the  more  marked  changes, 
which  we  are  quite  sure  the  secretion  must  undergo. 

A  patient  says  that  lie  is  "bilious;"  what  does  he  mean?  It  is 
quite  true  that  he  often  applies  the  term  to  a  variety  of  states 
which  we  know  to  have  nothing  in  common;  but  there  must  be 
some  general  type  to  which  they  all,  more  or  less,  approximate — 
there  is  something  which  we  may  rationally  call  by  that  name. 
The  symptoms  are  analogous  to  those  which  we  have  mentioned  as 
characterizing  a  fit  of  indigestion,  but  they  are  more  marked  and 
persistent;  and  though  in  many  cases  first  excited  by  an  indiscretion 
in  eating  or  drinking,  yet  this  antecedent  may  be  wanting,  and  the 
lasting  headache  and  discomfort  cannot  be  merely  the  effect  of 
sympathy  with  disordered  stomach:  there  must  be  some  material  in 
the  circulating  medium  which  ought  not  to  be  there;  and  its  fre- 
quent association  with  sense  of  weight  in  the  right  hypochondrium 


DISEASES  OP  THE  LIVER.  339 

and  pain  in  the  right  shoulder,  warrant  the  idea  that  the  fault  is  in 
the  eliminating  process  of  the  liver.  The  stools  are  often  dis- 
ordered, sometimes  paler  than  natural,  sometimes  darker,  leading 
to  the  belief  that  the  bile  is  deficient,  or  perverted.  _  The  general 
notion  of  biliousness  seems  to  be  nausea,  loss  of  appetite,  headache, 
foul  tongue,  probably  thirst,  and  disordered  bowels:  hence  we  find 
patients  in  the  early  stage  of  fever,  in  certain  conditions  of  phthisis, 
in  erratic  gout,  and  very  often  in  the  simple  functional  disorders  of 
stomach  and  bowels,  imagining  that  this  is  the  explanation  of  their 
sensations.  In  another  form  of  disease  the  analogy  is  much  more 
real ;  we  know  that  delirium  tremens,  and  disorder  of  the  liver,  are 
both  brought  on  by  habits  of  dissipation ;  and  it  may  be  admitted 
that  a  patient  is  not  far  wrong  who  calls  himself  "bilious;"  while 
his  white,  moist,  tremulous  tongue,  shaky  hand,  and  sleepless  eye 
point  him  out  as  being  on  the  verge  of  an  attack  of  delirium  a  potu. 
It  is  more  especially  that  form  of  the  disease  which  has  been 
designated  delirium  ebriosorum,  the  delirium  following  on  a  debauch, 
that  is  ushered  in  by  a  fit  of  biliousness. 

The  statement,  therefore,  of  the  patient,  that  he  is  bilious,  or 
subject  to  bilious  attacks,  must  first  be  analyzed  so  far  as  possible 
to  ascertain  what  are  his  actual  sensations;  and  from  these  we 
attempt  to  form  a  judgment  whether  the  liver  be  really  at  fault  or 
not.  In  the  history  of  the  case  we  can  seldom  trace,  with  any 
distinctness,  the  duration  of  the  illness;  because,  in  this  country  at 
least,  attacks  of  a  really  acute  type  are  seldom  seen,  and  the  sensa- 
tions in  others  are  not  very  definite  in  their  relation  to  this  organ. 
Under  all  circumstances,  the  period  during  which  the  patient  has 
been  conscious  of  derangement  of  health,  while  it  may  point  to 
some  change  occurring  at  the  time,  cannot  be  regarded  as  the 
necessary  commencement  of  the  disease  under  which  he  may  be 
labouring. 

§  1.  Inflammation— Congestion  —  Abscess. — Hepatitis,  which 
occurs  with  such  frequency  in  tropical  climates,  is  usually  associated 
among  ourselves  with  injury  to  the  side,  or  with  circumstances 
giving  rise  to  secondary  suppuration ;  very  rarely,  indeed,  does  any 
case  present  itself  in  which  some  such  antecedent  cannot  be  traced, 
for  its  association'with  chronic  dysentery  or  intestinal  ulceration 
is,  no  doubt,  a  phenomenon  of  the  same  kind.  The  sensations  of 
the  patient  refer  to  pain  or  sense  of  weight  on  the  right  side — 
perhaps  with  coincident  pain  in  the  right  shoulder:  we  observe 
some  indications  of  febrile  disturbance,  the  tongue  especially  being 
thickly  coated,  and  the  urine  loaded  with  pink  or  lateritious  sedi- 
ments :  perhaps  a  faint  bronzing  of  the  skin,  with  yellowness  of 
the  eyes,  exists  as  a  condition  of  partial  jaundice.  By  means  of 
palpation  and  percussion,  fulness,  tension,  and  tenderness  in  the 
right  hypochondrium  can  be  made  out,  along  with  dulness  extend- 
ing some  way  below  the  ribs.     The  patient  usually  lies  on  his  back, 


340  DISEASES  OF  THE  LIVER. 

and  complains  of  a  sense  of  dragging,  or  of  actual  pain,  in  the 
right  Bide,  if  lie  turn  on  the  left:  vomiting,  hiccup,  or  cough  may 
be  caused  by  the  extension  of  the  inflammation  to  adjoining  organs; 
and  frequently  pain  is  excited  on  deep  inspiration,  by  the  pressure 
of  the  diaphragm  on  the  liver  and  the  partial  movement  of  its 
inflamed  surface,  which  is  its  most  sensitive  part,  against  adjoining 
viscera.  It  is  almost  unnecessary  to  remind  the  student  that  an 
examination  of  the  chest  must  always  be  made  in  such  cases, 
because  the  whole  of  these  symptoms,  even  the  jaundice  itself,  may 
be  caused  by  an  attack  of  pleuro-pneumonia  on  the  right  side. 

In  congestion,  the  symptoms  by  which  our  attention  is  called  to  the  liver  as  the 
seat  of  disorder,  are  not  unlike  those  present  in  inflammation;  the  chief  difference 
is  the  absence  of  pyrexia:  in  the  hypochondriac  region  there  may  be  uneasiness, 
but  seldom  any  thing  more;  pain  is  more  constant  in  the  right  shoulder,  and  not 
unfrequent  in  the  right  iliac  region:  tenderness  is  only  rendered  perceptible  by 
pushing  the  fingers  deeply  under  the  ribs;  and  as  there  is  no  peritoneal  inflamma- 
tion, there  can  be  comparatively  no  irritation  of  adjoining  organs.  They  are  still 
more  distinguished  by  their  causes,  those  exciting  hepatitis  being  comparatively 
few,  while  congestion  may  be  produced  either  as  a  passive  state  by  obstructed  cir- 
culation, or  as  an  active  one  by  excesses  in  eating,  and  especially  in  drinking,  ex- 
posure to  cold,  or  inflammation  of  the  lungs  and  pleura. 

Considering  merely  the  results  of  pathological  research,  we  may  be  disposed  to 
believe  that  congestion  really  in  many  cases  passes  into  inflammation,  and  that 
the  existence  of  cirrhosis,  for  example,  proves  that  at  one  time  or  other,  perhaps 
on  several  occasions,  this  has  been  the  case:  clinically,  however,  we  have  not  the 
means  of  recognising  it;  and,  except  in  the  more  marked  instances,  we  must  be 
content  with  the  observation  that  the  liver  is  large  and  tender,  whether  that  be  an 
effect  of  congestion  only,  or,  more  properly,  of  a  form  of  inflammation. 

Abscess  of  the  liver  is  acknowledged  as  a  very  frequent  result 
of  true  hepatitis.  It  appears  either  as  a  single  cavity  filled  with 
pus,  or  as  a  number  of  smaller  abscesses:  the  former  is  the  case 
chiefly  when  the  inflammation  is  caused  by  injury,  the  latter  is  the 
form  always  presented  when  the  liver  has  been  the  seat  of  secondary 
suppuration ;  but  it  also  occurs  when  no  such  explanation  of  the 
hepatitis  can  be  offered.  Obscure  as  are  the  early  symptoms,  it  is 
still  more  difficult  to  say  with  any  degree  of  certainty  that  sup- 
puration has  taken  place,  except  when  the  matter  is  in  a  large  cyst 
and  comes  near  the  surface.  We  have  in  general  only  the  two  facts 
clearly  before  us  of  tenderness  and  enlargement  of  the  liver,  and 
of  the  recurrence  of  rigor;  but  there  are  so  many  other  circum- 
stances which  might  occasion  these  two  symptoms,  and  the  whole 
phenomena  of  the  case  are  so  complex,  that  any  definite  conclusion 
is  not  easily  arrived  at.  One  point  is  perhaps  deserving  of  especial 
notice,  that  the  general  disturbance  may  be  very  much  less  than 
could  have  been  anticipated  while  such  a  condition  existed:  the 
tongue  may  be  tolerably  clean,  the  skin  clear  and  free  from  jaun- 
dice, and  the  stools  may  be  tolerably  healthy,  which  is  not  what  we 
should  have  expected,  a  priori,  in  suppuration  of  the  liver. 

Another  form  in  which  a  similar  train  of  symptoms  is  presented 
is  when  suppuration  occurs  with  an  hydatid  cyst,  which  is  one  of 


ENLARGEMENT.  341 

the  common  causes  of  enlargement  of  the  organ:  its  existence  is 
sometimes  made  out  without  difficulty;  in  other  instances  we-cannot 
feel  any  confidence  in  the  diagnosis.  The  recurrence  of  rigor  and 
the  symptoms  of  hectic  are  among  the  circumstances  most  distinctly 
pointing  to  suppuration ;  and  these  must  he  weighed  with  the  signs 
of  the  presence  of  a  cyst,  or  in  a  still  more  general  manner,  with 
the  evidence  of  enlargement:  in  all  such  cases  an  opinion  must  be 
pronounced  with  much  hesitation. 

Diagnosis  in  all  of  these  cases  must  depend  in  great  measure  on  knowledge  of 
the  antecedent  circumstances,  and  readiness  in  perceiving  the  relation  which  they 
have  to  the  condition  of  the  liver.  And  while  this  knowledge  will  aid  in  preserving 
us  from  overlooking  symptoms  more  directly  traceable  to  that  viscus,  among  the 
complex  group  which  some  of  these  cases  present,  it  will  also  prevent  our  assuming 
congestion  or  inflammation  of  the  liver  as  an  explanation  of  an  obscure  case,  when 
its  exciting  causes  cannot  be  traced;  moreover,  such  an  assumption  is  not  war- 
ranted, unless  manifest  enlargement  can  also  be  made  out;  but  yet  enlargement 
is  not  of  itself  to  be  taken  as  evidence  of  inflammation.  Under  all  circumstances, 
such  cases  require  careful  analysis  of  symptoms,  and  cautious  exercise  of  judg- 
ment, before  venturing  to  pronounce  a  diagnosis;  and  the  opinion  must  always  be 
liable  to  modification  by  subsequent  events. 

§  2.  Enlargement. — Besides  the  congestive  or  inflammatory  in- 
crease of  size  which  is  transitory,  pathology  recognises  several  forms 
which  are  more  or  less  permanent:  certain  varieties  of  nutmeg-liver; 
fatty  degeneration,  including  that  which  is  now  called  lardaceous; 
and  also  enlargement  arising  from  the  presence  of  cancerous  growth 
and  of  hydatid  cysts.  To  us  the  only  question  of  importance  is,  are 
there  any  diagnostic  signs  by  which  these  conditions  may  be  dis- 
covered during  life? 

The  history  of  the  case  is  necessarily  entirely  silent  as  to  their 
origin ;  it  is  impossible  that  any  date  can  be  assigned  for  their  com- 
mencement; very  generally,  too,  there  is  scarcely  any  account  of 
symptoms  particularly  calling  attention  to  the  liver  until  the  disease 
has  reached  a  pretty  advanced  stage ;  there  may  have  been  jaun- 
dice, but  much  more  frequently  this  sign  is  wanting.  Persisting 
disorder  of  stomach  and  bowels,  attended  with  any  sensation  of  dis- 
comfort, should  lead  to  a  physical  examination  of  the  abdomen:  by 
percussion  it  is  not  difficult  to  detect  any  extension  of  dulness  below 
the  edges  of  the  ribs.  By  examination  of  the  chest,  it  may  be  as- 
certained that  the  liver  is  not  pushed  down  by  fluid  from  above; 
and  careful  palpation  determines  whether  its  edge  be  even  or  irre- 
gular, its  surface  smooth,  projecting,  or  knobbed.  The  coexistence 
of  phthisis  or  scrofula  would  suggest  its  being  possibly  fatty  or  lar- 
daceous; a  condition  occasionally  brought  about  in  childhood,  also, 
as  is  alleged,  by  over-feeding:  luxurious  living  and  over-stimulation 
of  the  organ  might  lead  us  to  conceive  that  it  would  have  the  "nut- 
meg" aspect  from  hypertrophy  of  the  secreting  apparatus:  the  ex- 
istence elsewhere  of  medullary  cancer  would  cause  a  suspicion  of 
this  form  of  disease ;  while  any  obstruction  to  the  circulation  might 
render  it  probable  that  it  was  merely  in  a  condition  of  passive  con- 
gestion. 


342  DISEASES  OF  THE  LIVER. 

By  careful  examination  we  can  generally  say  whether  the  disease 
have  tire  character  of  enlargement  or  of  morbid  growth,  just  in  so 
far  as  the  organ  retains  normal  shape  and  is  simply  hypertrophied, 
or  h:\*  acquired  any  unnatural  form.  Exceptions  to  this  rule  will 
be  found  in  cases  where  the  foreign  growth  is  limited  to  the  upper 
and  back  part  of  the  liver,  when  the  lower  edge  is  pushed  forward 
and  downward,  very  much  as  if  it  were  displaced  by  pressure  above 
the  diaphragm:  in  such  a  case  we  may  possibly  obtain  some  clue  to 
the  true  explanation  from  the  pleura  or  lung-structure  being  irri- 
tated by  pressure;  but, -as  a  general  rule,  this  does  not  occur  unless 
there  be  a  tendency  to  suppuration  and  ulcerative  action,  when  it 
seems  to  be  provided  as  a  means  of  protection  against  extravasation 
into  the  peritoneum. 

The  enlargement  of  interstitial  deposit,  whether  merely  the  consequence  of  con- 
stant and  repeated  congestion,  active  or  passive,  or  of  some  more  distinctly  mor- 
bid action,  as  seen  in  fatty  and  lardaceous  degeneration,  has  a  tendency  to  cause 
a  thickening  and  rounding  of  the  edge  of  the  liver,  while  its  general  contour  is  un- 
altered; and  when  this  can  be  made  out,  it  also  affords  direct  evidence  that  the 
organ  is  not  simply  displaced  downwards.  In  the  existence  of  morbid  growth,  if 
the  surface  or  the  edge  of  the  organ  be  at  all  irregular,  if  several  prominences  be 
perceptible  there  can  be  no  doubt  of  its  cancerous  nature;  but  if,  as  sometimes 
happens,  only  one  rounded  eminence  be  felt,  or  the  impression  be  that  one  lobe 
only  is  enlarged,  the  question  will  naturally  arise  whether  it  may  not  be  a  serous 
cyst,  which  we  know  to  be  a  common  form  of  morbid  growth  in  this  organ.  Oc- 
casionally, the  sense  of  fluctuation  is  so  distinct,  that  there  can  be  no  doubt  of  the 
presence  of  fluid;  but  very  often,  owing  to  the  thickness  of  the  parietes  and  the 
depth  from  the  surface,  it  is  almost  impossible  to  distinguish  the  elasticity  of  soft 
medullary  cancer  from  the  fluctuation  of  a  cyst  imbedded  in  such  a  solid  structure 
as  the  liver:  in  cases  of  doubt,  an  exploratory  puncture  may  be  made  with  a 
grooved  needle.  It  is  well  to  bear  in  mind,  however,  that  an  enlarged  gall-bladder 
has  been  mistaken  for  a  serous  cyst:  its  relation  to  the  edge  of  the  liver  which  can 
be  felt,  if  felt  at  all,  unaltered  in  form  and  above  the  fluctuating  tumour,  should 
prevent  such  an  error. 

The  occurrence  of  jaundice  in  any  of  these  cases  is  in  great  measure  accidental: 
it  is  not  the  destruction  of  the  tissue  of  the  gland  which  causes  the  discoloration 
of  the  skin  in  cases  in  which  it  occurs,  but  the  obstruction  of  a  duct  proceeding 
from  a  still  healthy  secreting  structure. 

§  3.  Cirrhosis. — Under  this  head  it  is  convenient  to  include  all 
the  forms  of  atrophy  of  the  liver  met  with  in  the  living  body,  as  we 
have  no  means  of  distinguishing  them  one  from  another. 

As  in  enlargement,  the  history  fails  in  pointing  out  when  cirrhosis 
commenced,  and  there  is  little  to  be  remarked  in  the  antecedent 
circumstances,  except  when  along  with  an  account  of  dyspeptic  at- 
tacks we  are  informed  of  previous  habits  of  dissipation:  gin-drink- 
ing being  known  as  one  of  the  most  common  causes  of  hob-nail  liver. 
There  may  have  been  jaundice  at  an  earlier  period,  and  even  in  the 
advanced  stages  there  is  often  a  degree  of  yellowness  of  the  scle- 
rotic ; — perhaps  some  illness  is  reported  which  may  seem  to  have 
had  the  characters  of  an  attack  of  inflammation,  but  this  is  not  com- 
mon. Our  attention  is  very  often  not  called  to  it  until  peritoneal 
effusion  has  caused  the  abdomen  to  swell;  and  in  a  large  proportion 


JAUNDICE.  343 

of  instances  in  which  ascites  has  been  gradually  developed,  and 
there  has  been  no  illness  to  ai'rest  the  patient's  attention,  until  the 
feeling  of  tightness  round  the  stomach  or  shortness  of  breathing 
leads  him  to  complain,  the  direct  cause  of  the  effusion  is  the  pre- 
sence of  cirrhosis.  In  his  general  aspect  the  patient  usually  pre- 
sents a  certain  degree  of  sallowness  of  skin,  and  he  is  always  more 
or  less  emaciated:  the  face  especially  becomes  thinner  in  this  dis- 
ease than  in  phthisis  or  cancer,  and  sometimes  the  bones  stand  out 
with  frightful  distinctness. 

On  examining  the  right  hypochondrium,  the  liver  is  found  to  be 
entirely  beyond  the  reach  of  the  fingers,  and  percussion  shows  that 
while  on  the  one  hand  the  ordinary  extent  of  liver  dulness  has  been 
diminished  in  the  direction  of  the  umbilicus  and  ilium,  it  also  does 
not  ascend  so  high  as  usual  in  the  chest,  in  short,  that  the  organ 
has  shrunk  in  every  direction. 

Another  form  of  disease  in  which  the  liver  loses  bulk  is  what  has 
received  the  name  of  yellow  atrophy:  it  is  invariably  accompanied 
by  jaundice,  and  this  symptom,  in  fact,  affords  the  only  indication 
of  its  existence. 

Occasionally,  in  scirrhus  the  actual  size  of  the  organ  is  diminished, 
the  natural  structure,  which  is  destroyed  by  the  disease,  not  being 
replaced,  as  in  the  medullary  forms  of  cancer,  by  morbid  growth  in 
equal  or  greater  amount.  It  would  be  vain  to  attempt  to  give  any 
rules  for  diagnosis  in  such  cases;  sometimes,  however,  there  is  pain, 
and  very  often  there  is  jaundice,  and  these  are  not  met  with  in  cir- 
rhosis; at  the  same  time  the  disease  is  one  of  slow  progress,  and 
attended  with  diminution  of  size:  the  hypothesis  of  sciwhus  would 
then  be  at  least  admissible. 

§  4.  Jaundice. 

In  the  present  state  of  pathology  we  must  be  content  to  admit  this  name  into 
our  classification,  although  it  be  but  a  symptom;  for  it  is  one  not  only  known  to 
be  dependent  on  various  forms  of  lesion,  but  it  is  also  one  of  which  very  frequently 
during  life,  and  occasionally  even  after  death,  we  cannot  determine  the  exact  cause. 
It  is  probable  that  in  all  cases  of  jaundice  some  change  has  really  occurred  in  the 
liver,  the  gall-bladder, .or  the  ducts;  but  even  this  has  been  denied:  progressive 
knowledge  may  ultimately  enable  us  to  assign  its  true  cause,  but  at  present  the 
name  is  a  convenient  oue  for  grouping  together  cases  which  cannot  be  included 
in  any  other  class  from  our  ignorance  of  their  true  nature,  while  they  present  this 
common  feature.  To  adopt  the  name  of  functional  disturbance  without  advancing 
in  any  way  our  real  knowledge,  would  only  deprive  us  of  the  advantage  which  the 
prominence  of  the  symptom  affords. 

Distinct  and  unmistakeable,  however,  as  it  would  seem  to  be,  an  inexperienced 
person  may  be  deceived.  A  patient  who  has  it  only  in  slight  degree  is  quite  sur- 
prised when  told  that  he  has  jaundice;  the  greenish  hue  of  chlorosis,  or  the  sallow 
earthy  aspect  of  malignant  disease,  or  the  yellowness  of  the  skin  in  pyamiia,  are 
all  apt  to  be  called  jaundice.  Its  clearest  indication  is  to  be  found  in  the  sclerotic 
coat  of  the  eye,  which  presents  in  the  chlorotic  or  malignant  condition  a  pearly  or 
bluish  lustre;  in  pyaemia  it  is  unchanged,  unless  jaundice  be  present.  However 
slight  the  tinge  of  the  skin  generally — and  in  dark  persons  it  very  often  has  only 
an  appearance  of  bronzing, — in  the  sclerotic  the  yellow  tinge  is  invariably  seen. 

The  circumstances  which  have  preceded  its  occurrence  chiefly  in- 


344  DISEASES    OF   THE    LIVER. 

dicatc  whether  it  has  been  brought  on  by  mental  emotion,  fright, 
&c,  or  whether  there  has  been  any  paroxysm  of  pain,  possibly  in- 
dicating the  presence  of  a  gall-stone  obstructing  the  duct;  pain, 
however,  is  not  essential  to  the  diagnosis  of  gall-stone.  The  exa- 
mination of  the  liver  may  prove  it  to  be  associated  with  congestion, 
enlargement,  or  contraction :  and  as  an  aid  to  diagnosis  it  has  been 
remarked  that  the  very  deep  shades  of  colour,  tending  to  a  greenish 
brown,  are  usually  associated  with  malignant  disease,  that  the  yel- 
lower shades  are  more  commonly  functional,  while  slight  bronzing 
is  often  seen  in  its  inflammatory  or  congestive  states.  Such  gene- 
ral inferences  must  not  be  too  much  relied  upon. 

The  liver  may  be  decidedly  shrunken  and  small ;  and  in  the  ab- 
sence of  symptoms  to  show  that  there  was  any  other  cause,  we  may 
suspect  the  existence  of  yellow  atrophy.  I  am  not  aware  that  there 
is  any  direct  evidence  by  which  it  can  be  proved:  it  presents  little 
difference  from  the  jaundice  dependent  on  functional  causes,  except 
in  the  severity  of  its  symptoms;  the  skin  becomes  intensely  yellow, 
the  brain  is  affected  by  blood-poisoning,  and  the  disease  is  rapidly 
fatal  from  this  cause:  it  is  by  some  classed  among  the  acute  dis- 
eases of  the  liver,  for  this  reason,  although  the  very  fact  of  its  being 
a  form  of  atrophy  seems  opposed  to  such  an  idea.  Cirrhosis  never 
of  itself  gives  rise  to  jaundice:  cancer,  with  shrinking  of  the  organ, 
very  commonly  leads  to  obliteration  of  some  duct,  and  the  effect  of 
this  will  be  the  existence  of  jaundice  of  very  dark  or  green  colour. 

When  the  organ  is  enlarged  merely  by  congestion,  the  slighter 
shades  of  jaundice  are  occasionally  seen:  when  it  has  become  abso- 
lutely increased  in  bulk  by  interstitial  deposit,  the  occurrence  of 
jaundice  must  be  due  to  some  extraneous  circumstance:  when  it  is 
enlarged  by  morbid  growth,  the  presence  or  absence  of  jaundice  de- 
pends on  the  position  of  the  abnormal  structure,  whether  it  be  so 
situated  as  to  obstruct  any  of  the  ducts.  In  the  jaundice  of  malig- 
nant disease  the  irregular  form  of  the  organ  sufficiently  explains  its 

origin. 

With  the  causes  of  the  emotional  and  functional  forms  of  jaundice 
we  are  very  little  acquainted,  except  when  it  is  produced  by  the 
displacement  of  a  gall-stone:  still  we  cannot  withhold  our  belief  that 
such  causes  act  in  some  unexplained  manner;  and  the  difficulty  of 
the  explanation  is  all  the  greater  in  that  it  does  not  appear  that 
mere  suppression  of  the  function  can  account  for  the  presence  of 
the  yellow  colour. 

The  condition  of  the  heart,  and  of  the  right  side  of  the  chest,  must  each  be  as- 
certained in  cases  of  jaundice,  because  of  their  association  with  congestion  of  the 
liver.  The  fteces  in  the  early  stage  almost  always  indicate  by  their  paleness  a 
deficiency  of  bile,  while  the  urine  receives  a  dark  porter-colour  from  the  bile  pass- 
ing out  of  the  system  by  this  channel.  It  is  generally  to  be  regarded  as  a  fa- 
vourable sign  when  the  clay-colour  of  the  stools  passes  off,  and  bile  begins  again 
to  be  seen  Tn  the  evacuations;  but  this  is  not  always  followed  by  a  cessation  of 
the  jaundice:  and  there  are  also  cases  in  which,  while  the  colour  of  the  skin  has 
been  gradually  developed,  the  motions  have  been  at  no  time  clay-coloured,  or  re- 


GALL-STONES.  345 

ruarkably  deficient  in  bile.  In  such  circumstances,  part  of  the  bile  finds  its  way 
into  the  intestine,  while  part  is  obstructed  and  absorbed  into  the  blood;  and  this 
might  happen  when  a  gall-stone  only  partially  closed  the  duct:  but  the  more  com- 
mon cause  is  when  one  of  its  main  branches  is  closed  by  the  pressure  of  a  morbid 
growth,  leaving  the  remainder  free,  and  then  the  jaundice  continues  to  increase  in 
inteusity. 

In  addition  to  these,  the  more  palpable  diseases  of  the  liver,  there  can  be  no 
doubt  that  the  secretion  must  be  variously  modified  under  conditions  of  functional 
disorder  with  which  we  are  yet  very  imperfectly  conversant;  but,  beyond  a  very 
few  broad  principles  of  diagnosis,  there  are  no  rules  which  can  be  laid  down  with 
sufficient  distinctness  to  form  any  basis  for  the  classification  and  arrangement  of 
tire  symptoms  to  which  they  give  rise. 

The  liver,  acting  as  one  of  the  great  emunctories  of  the  system,  secretes  from 
the  blood  a  large  proportion  of  excrementitious  matters,  but  along  with  this,  the 
secretion  is  made  subservient  to  the  purposes  of  intestinal  digestion:  hence  it  can 
readily  be  understood  that  in  all  derangements  of  function,  whether  connected 
with  organic  disease  or  not,  its  effects  may  be  traceable  either  in  the  one  set  of 
actions  or  in  the  other.  The  excrementitious  matters  may  not  be  properly  sepa- 
rated while  the  elements  necessary  to  digestion  continue  of  proper  quality  and 
amount;  or  these  may  be  either  such  as  to  retard  the  passage  of  the  freces  or  to 
accelerate  it — to  produce  constipation  or  diarrhoea,  and  so  might  be  spoken  of  as 
deficient  or  in  excess.  Further,  this  imperfect  elimination  may  depend  either 
on  the  blood  being  surcharged  with  materials  which  the  liver  cannot  separate  with 
sufficient  rapidity,  in  consequence  of  the  habits  of  the  individual,  or  the  fault  may 
be  in  the  liver  itself:  in  the  one  case  he  may  be  sallow  and  bilious,  while  yet  the 
stools  are  dark  and  relaxed;  in  the  other  the  sallow  hue  will  be  accompanied  by 
costive  and  rather  pale-coloured  evacuations.  These  terms  of  excess  and  deficiency 
of  bile  can  only  be  admitted  as  relative,  because  of  our  present  ignorance  of  the 
actual  changes  which  the  secretion  undergoes;  and  in  forming  a  diagnosis  we 
must  consider  quite  as  much  the  habits  of  the  patient,  and  the  probability  that  the 
bile-forming  elements  of  the  food,  and  consequently  of  the  blood,  are  in  excess  or 
defective,  as  the  actual  symptoms  under  which  he  is  labouring.  For  example,  we 
know  that  excessive  discharges  of  bile  give  rise  to  diarrhoea  ;  and  therefore  in  dis- 
orders of  the  alimentary  canal,  when  this  symptom  is  present,  and  is  associated 
with  other  conditions  (headache,  sallow  complexion,  &c.,)  which  we  call  bilious, 
we  conclude  very  naturally,  and  in  the  majority  of  instances  very  rightly,  that  a 
state  of  system  exists  which  is  characterized  by  an  excess  of  bile  or  bile-forming 
elements:  but  it  is  to  be  remembered  that  one  of  the  purposes  of  the  bile  is  to 
neutralize  the  acid  of  the  stomach,  and  if  the  food  continue  acid  in  the  alimentary 
canal,  it  will  excite  diarrhoea,  and  therefore  the  true  explanation  of  the  case  may 
be  that  the  liver  is  inactive,  and  the  excrementitious  matters  exist  in  the  blood, 
not  because  of  their  excess,  but  because  the  liver  fails  to  remove  them. 

In  attempting  to  form  any  opinion  on  this  subject  we  have  therefore  to  take 
into  consideration  the  history  of  the  individual,  as  that  may  tend  to  show  that  the 
organ  has  been  over-stimulated  in  past  times,  and  may  now  be  in  a  state  of  chronic 
disease;  his  present  habits,  as  informing  us  whether  the  bile-forming  elements 
are  supplied  in  too  great  or  in  too  small  quantity;  the  appearance  of  the  tongue, 
as  that  is  very  apt  to  present  a  dry  fur  in  disorder  of  the  liver;  and  the  colour,  as 
well  as  the  consistence  of  the  evacuations  from  the  bowels:  we  also  derive  instruc- 
tion from  the  urine,  which  is  more  prone  to  deposit  red  sediments  in  bilious  dis- 
orders than  most  others.  (See  Chap.  XXXI.  \  8.)  It  is  only  when  its  due  weight 
has  been  given  to  each  of  these  considerations  that  we  can  interpret  aright  the 
sallow  dingy  complexion,  the  headaches,  the  disagreeable  tastes  in  the  mouth, 
the  pains  in  the  side  and  shoulder,  and  all  the  anomalous  symptoms  which  such 
cases  present. 

§  5.  Gall-stones. — The  gall-bladder  may  be  full  of  these  concre- 
tions without  giving  rise  to  any  symptoms:  sometimes  they  are  so 
placed  as  to  act  as  a  kind  of  valve,  allowing  a  great  accumulation 


340  DISEASES    OF    THE    LIVER. 

of  bile  in  the  gall-bladder,  and  preventing  its  proper  evacuation: 
sometimes  they  pass  out  unperceived;  but  more  commonly,  \\hen 
disturbed,  their  passage  is  attended  with  great  pain,  and  occasion- 
ally they  arc  arrested  in  their  progress,  become  impacted  in  the 
duct,  and  can  only  make  their  escape  by  ulceration. 

The  pain  which  usually  attends  their  passage  is  not  difficult  to 
recognise;  it  is  severe,  tearing,  or  grinding,  without  tenderness, 
situated  at  the  pit  of  the  stomach,  with  a  sense  of  constriction  round 
the  waist;  it  is  not  accompanied  by  fever;  the  pulse  is  often  slower 
than  natural;  the  skin,  during  the  severity  of  the  paroxysm,  being 
cold ;  sometimes  there  is  distinct  rigour,  and  generally  flatulence, 
nausea,  or  vomiting:  then  comes  a  lull,  and  after  a  longer  or  shorter 
interval  the  paroxysm  of  pain  again  and  again  recurs,  until  the  con- 
cretion passes,  or  becomes  fairly  impacted.  The  more  frequently 
it  comes  on,  the  greater  is  the  probability  of  its  being  accompanied 
by  tenderness ;  but  yet  if  we  contrast  the  amount  of  tenderness  with 
the  severity  of  the  pain,  and  consider  that  no  febrile  symptoms  are 
excited,  there  is  little  chance  of  its  being  mistaken  for  inflamma- 
tion. When  jaundice  supervenes  it  gives  great  confirmation  to  our 
diagnosis;  but  it  is  by  no  means  a  constant  occurrence,  because  it 
is  only  when  the  stone  is  in  the  common  duct  of  the  liver  and  gall- 
bladder that  it  can  prevent  the  passage  of  bile  into  the  intestine. 

The  disorders  which  are  apt  to  be  mistaken  for  the  passage  of  gall-stones  are 
chiefly  two — in  one  the  diagnosis  is  of  ranch  importance,  in  the  other  it  is  not  very 
material:  the  one  is  local  peritonitis  excited  by  ulceration  of  the  stomach,  the  other 
mere  functional  disturbance  atteuded  with  flatulence,  especially  in  nervous  or  hys- 
terical persons.  In  one  or  two  points  peritonitis;  occurring  in  connexion  with 
ulcer  of  the  stomach  when  the  possibility  of  extensive  extravasation  is  limited  by 
local  adhesions,  is  very  analogous  to  the  passage  of  a  gall-stone:  its  sudden  incur- 
sion, its  severity,  its  position  and  limitation,  perhaps  the  rigour  at  its  first  occur- 
rence, are  much  the  same  in  both  cases:  but  they  are  manifestly  distinct  in  the 
constancy  of  pain,  in  the  tenderness  from  the  very  first,  and  the  acceleration  of 
pulse  which  invariably  accompany  peritonitis.  Functional  disorder  of  the  stomach, 
again,  is  so  commonly  accompanied  by  flatulence,  and  by  pain  as  a  consequence 
of  distention,  that  were  these  the  only  symptoms,  we  should  be  constantly  de- 
ceived by  persons  who  exaggerate  their  sensations.  We  have  to  remember,  how- 
ever, that  up  to  the  moment  of  pain  being  produced  by  the  entrance  of  the  calcu- 
lus into  the  duct,  the  patient  has  had  no  dyspeptic  symptoms,  no  discomfort  alter 
meals,  no  flatulence;  it  begins  instantaneously:  the  pain  of  dyspeptic  flatulence, 
on  the  other  hand,  has  been  gradually  increasing  in  intensity  for  days  or  weeks, 
and  it  is  only  after  some  indiscretion  in  food,  or  along  with  some  mental  anxiety 
or  cause  of  depression,  that  it  attains  the  severity  which  can  at  all  be  mistaken  for 
any  thing  else;  and,  again,  the  general  symptoms,  the  coldness  of  skin  and  depres- 
sion of  the  circulation,  produced  by  the  reality  of  pain,  in  the  one  case,  cannot  be 
simulated  by  the  exaggerated  expression  of  it  in  the  other,  nor  can  the  paroxysms 
be  readily  imitated.  Gout  in  the  stomach,  on  the  other  hand,  may  chiefly  be  dis- 
tinguished by  its  being  a  single  seizure, — not  alternating  in  relief  and  exacerba- 
tion,— by  the  diffuse  character  of  the  pain,  and  the  absence  of  the  sense  of  con- 
striction so  generally  felt  in  the  passage  of  a  gall-stone. 

Division  II. — Diseases  of  the  Spleen. 
Of  the  diseases  of  the  spleen  we  have  still  fewer  means  of  dia- 
gnosis than  of  those  of  the  liver.    We  know  that  it  is  often  involved 


CANCER  OF  THE  PANCREAS.  347 

in  blood  diseases,  that  especially  in  fevers  it  becomes  almost  dis- 
integrated, and  that  in  pysemia  it  is  the  seat  of  secondary  deposits, 
capillary  phlebitis,  and  suppuration ;  but  we  know  nothing  of  the 
indications  which  mark  these  conditions,  as  they  are  wholly  obscured 
by  the  more  general  symptoms  of  disease. 

Its  enlargement  alone  becomes  cognizable  to  us  by  its  abnormal 
extent  and  by  its  position  in  the  abdominal  cavity.  And  if  per- 
cussion and  palpation  be  properly  employed,  there  can  be  no  dif- 
ficulty, when  a  tumour  is  recognised,  in  tracing  it  upwards  towards 
the  left  hypochondrium,  and  so  making  sure  that  it  is  the  spleen, 
even  when  it  is  first  discovered,  as  in  cases  of  very  great  enlarge- 
ment, in  the  right  iliac  region.  The  two  essential  characters  by 
which  it  is  known  are  these:  its  oval  form,  with  smooth  rounded 
surface ;  and  its  point  of  attachment  under  the  false  ribs  on  the  left 
side ;  the  only  possible  excuse  for  a  mistake  can  be  when  the  abdo- 
minal cavity  is  distended  with  fluid. 

In  its  history  it  will  sometimes  be  found  to  be  a  sequel  of  inter- 
mittent fever,  commonly  known  as  ague-cake.  Very  often  no  pre- 
cursory phenomena  are  discovered,  and  its  cause  is  quite  unknown; 
occasionally  it  is  associated  with  enlargement  of  the  liver,  and  pro- 
bably then  both  arelardaceous.  It  is  intimately  connected  with  an 
ancemic  state  of  blood;  and  as  its  functions  in  reference  to  the 
elaboration  of  this  fluid  become  better  understood,  we  shall  pro- 
bably obtain  more  direct  indications  of  the  changes  which  it  under- 
goes in  disease:  at  present  we  can  only  affirm  that  there  seems  to 
be  some  close  relation  between  one  of  the  forms  of  enlargement 
and  the  condition  already  referred  to  as  white-cell-blood.  (Chap. 
VIII.,  §  2.)  In  consequence  of  this  circumstance  it  may  be  also 
associated  with  general  dropsy;  with  ascites  it  would  seem  to  be 
connected  only  through  the  medium  of  concomitant  disease  of  the 
liver. 

Division  III. — Disease  of  the  Pancreas. 

The  only  known  disease  of  the  pancreas  which  can  be  made  the  subject  of  dia- 
gnosis is  its  cancerous  degeneration.  It  never  stands  alone,  but  is  always  con- 
joined with  cancer  of  the  stomach  or  duodenum:  its  position  is  such  that  it  is  not 
possible  to  determine  whether  the  hardened  mass,  which  can  sometimes  be  felt 
during  life,  belongs  to  the  pancreas  or  to  the  stomach.  Our  only  reason  for  men- 
tioning it  is,  that  it  has  been  sometimes  found  after  death  in  cases  of  diarrhoea 
adiposa,  and  theory  rather  gives  countenance  to  the  idea  that  the  one  event  may 
be  dependent  on  the  other.  Cancer  of  the  pancreas,  however,  has  been  seen  much 
hiore  frequently  than  diarrhoea  adiposa;  and  we  cannot  at  present  assign  any  sa- 
tisfactory reasons  why  the  association,  if  really  standing  in  the  relation  of  c#use 
and  effect,  should  be  occasionally  broken  through.  A  suspicion  may  be  reason- 
ably entertained  that  there  is  cancer  of  the  pancreas  when  a  hard  mass  can  be 
detected,  as  it  occasionally  may  be  when  the  stomach  is  empty,  more  to  the  left 
than  is  usually  met  with  in  cancer  of  the  stomach,  and  when  among  the  symptoms 
of  disordered  digestion  and  nutrition  we  do  not  find  frequent  vomiting,  and  the 
matters  ejected  are  never  grumous  or  mixed  with  blood. 


343 


CHAPTER  XXX. 


EXAMINATION    OF   TEE    URINE. 


General  Considerations — Analysis  of  Urine. — §  1,  Acidity — §  2, 
Specific  Gravity — §  8,  General  Appearance — Colour — Transpa- 
rency— §  4,  Sediments — (a)  Chemical  Constitution — (b)  Micro- 
scopic Appearances — Organic  Substances — Crystalline  Bodies — 
§5,  The  Urine  free  from  Sediment — (a)  Albumen — (b)  Sugar — 
(c)  Urea. 

We  next  proceed  to  a  consideration  of  the  diagnostic  points  con- 
nected with  diseases  of  the  urinary  organs:  our  knowledge  on  this 
subject  is  in  great  measure  derived  directly  from  the  condition  of 
the  urine,  and  we  must  therefore  inquire  with  some  minuteness  into 
the  changes  which  it  undergoes.  In  doing  so  we  shall  find  that  in 
very  many  instances  its  abnormal  states  are  dependent  on  diseases 
of  distant  organs,  by  which  the  function  of  the  kidney  merely  is 
interfered  with,  while  no  actual  change  passes  on  the  structure  of 
that  organ;  but  as  our  object  is  to  ascertain  the  bearing  of  symp- 
toms upon  the  condition  of  the  patient,  no  apology  need  be  offered 
for  bringing  together  here  all  these  varieties,  whether  belonging  to 
diabetes,  to  the  lithic  acid  diathesis,  as  it  is  called,  or  even  simply 
to  dyspepsia;  although  it  must  be  understood  that  they  do  not  rank 
in  a  pathological  sense  as  diseases  of  the  urinary  organs. 

Probably  a  large  field  of  observation  remains  open  which  may  at 
some  future  period  be  made  available  for  the  discrimination  of  dis- 
ease, and  the  treatment  of  the  patient,  in  ascertaining  the  relative 
amount  of  the  various  normal  ingredients  of  the  urine ;  but  at  present 
the  variations  to  which  they  are  subject  must  be  left  to  those  who 
have  made  chemistry  their  special  study :  our  attention  must  be  limit- 
ed to  changes  which  are  easily  appreciated  and  readily  recognised. 
Let  me  only  caution  the  student  against  what  may  be  called  rough- 
and-ready  tests,  and  deductions  based  upon  inaccurate  investiga- 
tions: it  would  be  well  if  he  knew  how  to  make   a  quantitative 
analysis  of  the  different  products,  because  mistakes  are  continually 
being  made  in  practice  from  ignorance  on  this  point,  as  when,  for 
example,  an  unusual  manifestation  of  the  presence  of  any  ingredi- 
ent, by  precipitation  or  otherwise,  is  taken  as  evidence  of  its  being 
present  in  excess, — a  conclusion  which  may  be  true,  or  may  be 
utterly  false.     Unfortunately  quantitative  analysis  is  exceedingly 
difficult,  but  we  may  at  least  secure   accuracy  in  the  qualitative 
analysis,  and  this  must  never  be  overlooked:  it  is  exceedingly  un- 
wise to  attempt  to  decide  on  the  characters  of  the  urine  by  boiling 
it  in  a  spoon  over  a  candle,  when  we  can  always  carry  away  a  por- 


EXAMINATION    OF    THE    URINE.  349 

tion  and  examine  it  -with  a  test-tube  and  in  a  spirit-lamp.  Most 
especially  in  commencing  the  study  is  it  important  to  attain  accu- 
rate results ;  if  this  be  attended  to  in  the  first  instance,  it  will  give 
a  much  greater  readiness  in  subsequent  investigations;  and  no  op- 
portunity of  making  observations  should  be  lost,  until  this  accuracy 
and  readiness  are  attained.  However  definite  the  rules  laid  down, 
fallacies  can  only  be  avoided  by  frequent  practice. 

The  chemical  tests  in  constant  use  are  the  coloured  papers  for  ascertaining  the 
acid  or  alkaline  reaction  of  the  urine,  the  urinometer,  for  determining  its  specific 
gravity,  and  the  observation  of  the  changes  produced  by  the  addition  of  acid  and 
alkali  and  the  application  of  heat.  Before  proceeding  further  it  may  be  well  to 
say  a  few  words  on  each  of  these  points. 

The  urine  is  naturally  acid  under  ordinary  circumstances,  and  care  must  be 
taken  in  pronouncing  it  unusually  so  from  the  effect  produced  on  the  test-paper, 
because  all  test-papers  are  not  alike ;  one  becomes  very  much  reddened  by  acidity 
which  only  slightly  alters  another.  In  conditions  of  alkalescence  it  is  important 
to  have  the  test-paper  as  delicate  as  possible,  because  the  reaction  is  frequently 
very  weak.  Alkalescence  due  to  ammonia,  if  not  distinguished  by  the  smell,  may 
be  readily  recognised  by  the  action  of  heat,  which  dissipates  the  volatile  alkali, 
and  restores  the  colour  of  the  paper. 

The  urine  taken  for  the  purpose  of  determining  the  specific  gravity  should  be, 
if  possible,  obtained  from  a  large  quantity;  each  time  that  urine  is  passed  in  the 
twenty-four  hours  it  varies  somewhat  in  specific  gravity,  and,  as  an  isolated  fact, 
its  increase  or  decrease  is  of  little  value  unless  it  be  found  persistent  on  repeated 
trials. 

In  the  application  of  heat  and  nitric  acid,  the  student  will  find  it  advantageous 
to  manipulate  with  at  least  three  distinct  portions  of  urine.  He  should  pour  about 
an  ounce  into  a  precipitate  glass,  and  then  add  cautiously  nearly  a  drachm  of 
strong  acid;  this  will  sink  to  the  bottom  of  the  glass  if  poured  down  its  side,  and 
if  any  reaction  take  place  between  the  two  fluids  it  will  be  distinctly  seen  at  their 
line  of  junction.  He  should  then  pour  a  small  quantity  of  urine  alone  (half  a 
drachm  is  quite  enough,  and  better  than  a  larger  quantity)  into  a  test  tube,  and 
boil  over  a  spirit  lamp,  and  then  add  one  or  two  drops  of  acid.  To  a  third  quan- 
tity he  should  add  a  few  drops  of  acid  while  cold,  and  then  boil.  In  all  cases  in 
which  heat  is  employed  he  should  be  careful  to  add  neither  too  much  nor  too  little 
acid;  a  large  quantity  produces  chemical  decomposition,  which  may  be  perplexing, 
and  a  single  drop  of  acid  sometimes  prevents  the  precipitation  of  the  albumen, 
which  it  is  our  great  object  to  accomplish  by  these  means. 

In  the  use  of  alkali  a  considerable  quantity  is  generally  needed,  and  mistakes 
are  more  likely  to  be  made  by  boiling  with  too  small,  than  with  too  large  a  pro- 
portion:  its  action  ought  always  to  be  aided  by  the  application  of  heat;  tbere  are 
scarcely  any  points  which  can  be  solved  by  its  admixture  with  the  urine  at  or- 
dinary temperatures. 

In  proceeding  with  the  analysis  of  the  urine  we  will  direct  our 
attention  (1)  to  its  degree  of  acidity,  (2)  its  specific  gravity,  (3)  its 
general  appearance,  (4)  the  chemical  constitution  and  microscopical 
appearance  of  its  sediments,  (5)  to  the  effects  produced  on  the  clear 
fluid  by  various  reagents. 

§  1.  Acidity  and  Alkalescence. — The  degree  of  acidity  can  only 
be  guessed  at  by  the  change  of  colour  which  test-paper  undergoes: 
it  differs  in  health  at  various  periods  of  the  day,  and  has  been  as- 
certained to  become  even  alkalescent  during  digestion  in  persons 
who  appeared  to  be  perfectly  healthy.     Excessive  acidity,  whether 


3o0  EXAMINATION    OF   THE    URINE. 


« 


occurring  only  at  certain  periods  in  the  twenty-four  hours,  or  cha- 
racterizing the  whole  quantity  passed,  indicates  faulty  assimilation; 
it  may  be  due  either  to  the  formation  of  an  unusual  quantity  of 
lithic  acid,  or  to  acid  generated  in  the  stomach  during  digestion, 
■which  subsequently  passes  into  the  circulation,  and  then  appears 
in  the  urine:  acidity  due  to  the  former  cause  is  more  constant,  that 
produced  by  the  latter  more  marked  after  any  excess  in  eating  or 
drinking. 

Alkalescence  depends  upon  two  very  distinct  causes — deficiency 
of  acid,  and  decomposition:  the  former  indicated  by  an  excess  of 
fixed  alkali,  the  latter  by  the  presence  of  free  ammonia.  The  smell 
is  generally  sufficient  to  discriminate  these  two  conditions,  and  any 
doubt  may  be  removed  by  heating  the  test-paper  after  use.  This 
deficiency  of  acid,  when  it  exists  as  a  permanent  condition,  either 
characterizing  the  whole  of  the  urine  voided  throughout  the  day,  or 
at  least  recurring  very  frequently,  is  that  to  which  the  name  of 
phosphatic  diathesis  was  once  applied,  because  it  is  generally  ac- 
companied by  a  deposit  of  the  earthy  phosphates  which  are  inso- 
luble in  alkaline  solutions:  it  generally  implies  a  low  state  of  vi- 
tality, and  more  particularly  nervous  depression,  resulting  from 
exhaustion  of  the  nervous  system  by  mental  anxiety,  spermatorrhoea, 
&c.  Similar  results  are  occasionally  met  with  from  transient  cir- 
cumstances: a  person  whose  urine  is  usually  neutral  or  slightly  acid 
will  pass  very  alkaline  urine  for  a  short  time  at  the  commencement 
of  digestion,  when  suffering  from  acid  dyspepsia;  most  remarkable 
examples  of  this  may  be  seen  during  the  fermentation  of  the  food 
in  cases  of  sarcina  ventriculi.  Another  accidental  cause  is  the  in- 
gestion of  a  large  quantity  of  any  of  the  vegetable  salts  which  are 
decomposed  in  the  system,  e.  g.,  the  tartrate  or  citrate  of  potash  or 
soda. 

The  presence  of  volatile  alkali  depends  chiefly  on  decomposition; 
and  in  by  far  the  larger  number  of  cases  is  due  to  imperfect  empty- 
ing of  the  bladder,  which  causes  the  secretion  of  unhealthy  mucus 
or  pus  from  its  lining  membrane:  the  idea  that  deficient  nervous 
energy  in  paraplegia  was  the  direct  cause  of  decomposition  is  now 
abandoned.  In  certain  states  the  urine  passes  more  rapidly  into 
decomposition  than  in  others;  and  it  would  appear  that  deficiency 
of  acid,  amounting, only  to  its  being  slightly  below  the  ordinary 
standard,  along  with  excessive  secretion  of  mucus  from  the  bladder, 
though  not  actually  morbid,  may  excite  this  change  very  soon  after 
the  urine  is  evacuated;  and  the  same  effect  may  be  produced  by 
impurities  in  the  vessel  in  which  it  is  contained — a  very  small  quan- 
tity of  animal  matter  in  a  state  of  change  speedily  rendering  the 
urine  fetid.  This  condition  is  very  different  from  that  just  adverted 
to,  when  inflammation  of  the  bladder  exists:  in  the  one  decom- 
position takes  place  after  the  urine  has  left  the  bladder,  in  the  other 
the  urine  is  ammoniacal  when  passed:  the  one  occurs  in  states 
closely  analogous  to  those  in  which  fixed  alkali  is  commonly  present, 
the  other  is  restricted  to  the  cases  of  local  disease. 


GENERAL   APPEARANCE. ]  351 

§  2.  Specific  Gravity. — By  means  of  the  urinometer  we  ascer- 
tain how  far  urine  differs  in  specific  gravity  from  pure  water:  and 
it  is  of  great  importance  to  bear  in  mind  that  the  instrument  does 
no  more.  It  shows  how  much  soluble  matter  heavier  than  water  is 
contained  in  a  given  quantity  of  fluid,  but  it  does  not  teach  what 
that  solid  matter  is.  It  may  consist  of  salts,  of  urea,  or  of  sugar, 
and  we  can  only  determine  its  nature  by  chemical  analysis.  A 
generally  high  or  low  specific  gravity,  as  ascertained  by  testing  a 
portion  of  the  mixed  secretion  of  the  whole  day,  and  especially  when 
found  persistently  so  by  repeated  examination  from  day  to  day,  is 
of  more  importance  than  any  one  evacuation  of  the  bladder  being 
above  or  below  the  average.  In  estimating  the  importance  of  spe- 
cific gravity  as  an  indication  of  disease,  we  have  to  take  into  account 
the  quantity  passed  during  the  twenty-four  hours.  Any  deviation 
from  the  normal  standard  is  of  value  when  the  average  quantity  of 
urine  is  secreted,  but  it  may  be  taken  as  evidence  of  disease  if  a 
high  specific  gravity  accompany  excessive  secretion,  or  a  low  spe- 
cific gravity  be  noted  when  the  urine  is  scanty.  The  observation 
that  at  any  one  period  of  the  day  the  specific  gravity  is  much  above 
the  standard  may  lead  to  the  detection  of  some  disorder  in  the  as- 
similating processes  which  would  otherwise  escape  notice:  its  being 
casually  below  the  standard  is  of  little  moment;  it  is  not  uncommon 
in  hysteria ;  it  may  happen  in  consequence  of  the  person  having 
imbibed  an  unnecessary  quantity  of  liquid,  or  having  taken  some 
aliment  or  stimulant  which  has  accidentally  acted  as  a  diuretic.  The 
circumstances  under  which  the  more  important  variations  occur 
must  be  again  adverted  to:  it  need  only  be  stated  here,  that  when 
persistent,  the  minimum  is  observed  in  albuminuria,  the  maximum 
in  diabetes. 

§  3.  General  Appearance. — The  urine,  after  standing  some  time 
in  the  vessel,  may  be  perfectly  transparent,  throughout,  mv  a  sedi- 
ment may  rest  at  the  bottom,  leaving  the  supernatant  fluid  quite 
clear:  in  other  cases  the  whole  is  more  or  less  opaque;  and  this 
opacity  may  increase  towards  its  lower  part,  or  in  addition  there 
may  be  a  distinct  deposit. 

a.  Transparent  urine  varies  in  colour  from  a  pale  yellow,  hardly 
perceptible,  to  a  deep  amber,  in  conditions  of  health;  and  within 
certain  limits  these  variations  are  proportional  to  the  amount  of 
animal  matters  present.  When  the  colour  is  deep,  the  relative 
amount  of  water  is  usually  small,  and  the  specific  gravity  high,  and 
very  generally  the  salts  as  well  as  the  extractive  matters  are  in  ex- 
cess, and  are  deposited  when  the  urine  is  cold,  unless  they  be  held 
in  solution  by  some  unusual  circumstance.  In  all  cases  of  diuresis 
the  urine  is  pale  and  limpid  from  an  excess  of  water,  and  perhaps 
the  absence  of  colour  is  most  striking  after  an  hysterical  paroxysm. 

Deep-coloured,  transparent  urine  may  be  taken  generally  as  in- 
dicating excessive  metamorphosis  of  tissue;  it  has  perhaps  a  more 


352  EXAMINATION   OF   THE   URINE. 

intimate  relation  to  the  secretion  of  colouring  matter  by  the  liver 
than  to  any  other  circumstance.  When  the  blood  becomes  satu- 
rated  with  bile  in  jaundice,  the  urine  acquires  the  colour  of  porter; 
and  it  is  only  by  pouring  a  small  quantity  into  a  white  porringer  or 
into  a  test-tube  that  we  can  satisfy  ourselves  that  it  is  not  opaque. 
This  condition  is  essentially  different  from  the  secretion  of  dark- 
coloured  urine  of  high  specific  gravity,  although  the  shade  of  colour 
in  slight  jaundice  maybe  exactly  the  same.  It  may  be  added  here, 
as  we  shall  not  have  again  occasion  to  refer  to  it,  that  the  addition 
of  nitric  acid,  converting  the  colour  into  green,  is  the  readiest  test 
of  the  actual  presence  of  biliary  colouring  matter  in  the  urine. 

b.  When  the  whole  of  the  urine  is  opaque,  it  presents  either  an 
appearance  of  unusual  whiteness,  in  consequence  of  the  minute 
opaque  particles  being  colourless ;  or  it  is  unnaturally  dark  from  the 
adventitious  presence  of  colouring  matter,  and  this  is  most  com- 
monly derived  from  an  admixture  of  blood. 

The  white  varieties  are  chiefly  of  two  kinds — an  admixture  of 
mucus  or  pus,  and  turbidity  as  caused  by  chemical  decomposition ; 
the  two  being  very  often  found  together.  Healthy  mucus  floats  as 
a  cloud,  which  may  leave  the  edges  nearly  transparent  as  it  accu- 
mulates towards  the  bottom  of  the  vessel:  pus  renders  the  whole  of 
the  urine  more  or  less  opaque,  but  forms  a  distinct  sediment  when 
allowed  to  stand,  very  often  carrying  down  with  it  some  portion  of 
earthy  salts:  altered  pus,  or  ropy  mucus  as  it  used  to  be  called, 
collects  into  a  stringy  mass  at  the  lower  part  of  the  vessel,  the  whole 
urine  being  turbid  from  decomposition:  urine  mixed  with  leucor- 
rhoeal  discharge,  and  that  which  is  altered  by  decomposition,  are 
both  wholly  opaque ;  if  there  be  any  sediment  it  is  quite  independent 
of  the  opacity,  which  has  no  tendency  to  form  a  deposit. 

Opaque  urine  of  deep  colour  may  be  produced  by  a  combination 
of  one  of  the  white  varieties  with  colouring  matter  of  bile,  which  is 
of  itself  really  transparent;  in  such  cases  the  existence  of  jaundice 
would  explain  its  meaning:  it  is  much  more  commonly  produced  by 
a  certain  admixture  of  blood,  when  the  colour  varies  from  a  pinkish 
hue  to  a  deep  brown.  These  varieties  depend  more  upon  the  con- 
dition of  the  urine  itself  than  upon  the  causes  which  give  rise  to  the 
effusion  of  blood;  alkalescence  or  acidity  is  especially  prone  to  pro- 
duce such  changes;  but  as  a  general  rule  the  passive  hemorrhage 
occurring  in  organic  disease  of  the  kidneys  is  far  more  frequently 
brownish  than  pink.  It  sometimes  gives  merely  a  slight  smokiness 
to  the  urine,  which  is  then  rather  hazy  than  opaque.  When  more 
severe  and  more  active  hemorrhage  occurs  coagula  are  often  found 
of  such  size  as  to  be  readily  recognised  by  the  naked  eye:  microscopic 
examination  affords  some  assistance  in  determining  to  which  of  these 
causes  the  blood  is  to  be  attributed. 

§  4.  Sediments. — In  a  very  large  number  of  instances,  by  allow- 
ing the  urine  to  stand  for  some  hours  after  it  has  cooled,  a  sediment 


SEDIMENTS — CHEMICAL    CHARACTERS.  353 

is  deposited,  which  sometimes  can  only  be  discovered  by  placing  a 
drop  from  the  bottom  of  the  vessel  under  the  microscope,  but  is  of- 
ten readily  perceptible.  These  sediments  are  partly  formed  of  sub- 
stances which  'are  merely  intermixed  "with  the  urine,  and  not  dis- 
solved in  it;  partly  of  soluble  materials,  some  of  which  are  more 
freely  dissolved  in  urine  at  the  temperature  of  the  body  than  at  the 
temperature  of  the  air,  the  excess  being  deposited  as  it  cools;  and 
partly  of  elements  which  are  more  soluble  in  one  form  of  combina- 
tion than  another,  and  after  the  lapse  of  a  few  hours  are  slowly 
precipitated  in  consequence  of  spontaneous  chemical  change. 

They  vary  much  in  their  general  character  and  appearance,  so 
that  an  experienced  observer  frequently  can  pronounce  with  accu- 
racy as  to  their  nature  from  mere  inspection ;  but  it  seems  to  me 
better  to  classify  them  according  to  their  chemical  relations  and 
their  microscopical  characters;  and  as  we  proceed,  any  peculiar  ap- 
pearances will  be  mentioned  which  they  more  commonly  present  to 
the  naked  eye.  The  supernatant  fluid  should  be  first  carefully 
decanted  off  for  separate  analysis ;  and  if  any  part  of  it  be  perfectly 
transparent,  this  should  be  placed  by  itself,  as  the  evidence  of  the 
presence  of  albumen  in  small  quantity  is  so  much  more  satisfactory 
in  a  transparent  fluid. 

a.  Chemical  relations. — A  portion  of  the  sedimentary  urine  is  to 
be  poured  into  a  test-tube,  taking  care  not  to  fill  it  to  more  than  an 
inch  in  depth  (students  often  puzzle  themselves  by  using  too  large  a 
quantity,)  heat  is  then  applied,  and  as  the  temperature  rises  we  ob- 
serve the  following  effects. 

1.  The  deposit  is  entirely  dissolved.  It  is  wholy  composed  of 
the  urates  and  chiefly  of  the  urate  of  ammonia.  This  sediment  pre- 
sents a  flocculent  appearance,  is  sometimes  quite  white,  but  more 
generally  it  is  coloured  of  a  brown,  yellow,  orange,  or  pinkish  hue,  and 
when  the  red  tinge  is  distinct,  it  is  scarcely  necessary  to  use  any 
test  to  ascertain  its  character;  no  other  red-coloured  deposit  has  the 
same  flocculent  appearance:  the  urine  is  always  acid. 

2.  It  does  not  disappear  with  heat.  One  or  two  drops  of  acid 
are  then  to  be  added  to  the  heated  fluid:  if  it  now  dissolve,  we  know 
that  it  consisted  of  earthy  salts,  probably  in  combination  with  phos- 
phoric acid.  These  are  always  white,  but  do  not  present  any  ap- 
pearance sufficient  at  once  to  distinguish  them;  they  generally 
abound  in  alkaline  urine. 

3.  It  is  unaffected  by  hydrochloric  acid,  but  dissolves  on  the  free 
addition  of  nitric  acid;  and  it  is  also  soluble  in  alkali.  This  deposit 
consists  of  uncombined  uric  acid:  its  general  characters  are  very 
marked;  it  is  heavy,  readily  falling  to  the  bottom  of  the  tube  after 
agitation,  and  presents  to  the  naked  eye  the  appearance  of  red  sand; 
it  can  only  be  confounded  with  blood-globules,  which  sometimes  have 
a  similar  sand-like  character,  but  are  not  nearly  so  heavy,  and  are 
only  found  in  urine  partly  opaque:  they  are  quite  insoluble. 

4.  It  does  not  disappear  with  heat  and  acid.     To  a  fresh  portion 

23 


354  EXAMINATION    OF    THE    URINE. 

add  freely  liquor  potassse,  and  boil;  the  greater  part  is  dissolved, 
and  by  gently  prolonging  the  heat  the  undissolved  portion  collects 
into  a  mass,  which  floats  in  perfectly  transparent  fluid.  Such  a 
sediment  is  probably  composed  chiefly  of  pus,  the  undissolved  por- 
tion being  earthy  salts,  which  are  precipitated  either  in  part  or 
wholly  after   the  alkali  was  added.     When   the  amount  of  pus  is 

isiderable  vre  shall  find,  on  pouring  the  fluid  out  of  the  test-tube, 
that  it  has  acquired  an  adhesive  property;  it  is  called  ropy  because 
it  clings  in  lengthened  strings  to  the  lip  of  the  tube  in  place  of 
dropping  freely.  This  sediment  cannot  be  distinguished  by  the 
naked  eye  from  white  lithates  or  phosphates;  the  urine  is  seldom 
strongly  acid,  and  does  not  become  transparent  when  the  deposit 
has  fallen;  it  shows  a  great  tendency  to  become  alkaline,  and  then 
the  pus  becomes  adhesive,  and  is  gradually  converted  into  a  ropy 
mass.  * 

5.  When  part  of  the  sediment  dissolves  with  heat,  the  remainder 
must  be  tested  in  the  same  manner  both  with  nitric  acid  and  with 
liquor  potassre;  and  we  may  thus  determine  that  there  exists  along 
with  the  urates  an  admixture  either  of  earthy  salt  which  is  very 
often  oxalate  of  lime,  or  of  crystalline  uric  acid,  of  pus,  or  of  blood. 

Such  are  the  general  answers  which  chemistry  affords  as  to  the  nature  of  sedi- 
ments; and  the)7  have  been  stated  in  broad  outline  because  the  more  delicate  and 
intricate  results  are  really  unnecessary  when  we  have  the  microscope  to  appeal  to 
in  all  cases  of  doubt;  and  the  few  facts  above  referred  to  are  the  only  ones  of  real 
importance  in  treatment.  In  a  very  large  proportion  of  cases  the  sediment  is 
composed  of  urates;  and  according  to  the  present  belief  of  chemists,  the  form  of 
combination  in  which  the  uric  acid  exists  is  that  of  urate  of  ammonia.  This  class 
of  salts  is  at  once  recognised  by  their  ready  solution  by  heat:  and  when  the  urine 
becomes  perfectly  transparent  there  can  be  no  doubt  as  to  their  true  character. 

Not  unfrequently,  when  the  earthy  salts  are  present,  some  portion  of  the  sedi- 
ment dissolves  by  heat:  this  is  due  to  an  admixture  of  the  urates;  as  soon  as  the 
temperature  has  reached  the  boiling-point  there  can  be  no  further  solution  by  heat, 
and  we  add  one  or  two  drops  of  acid;  the  phosphates  are  dissolved  with  the  utmost 
facility.  Any  acid  may  suffice,  but  it  is  well  to  remember  that,  of  those  in  com- 
mon use  as  tests,  the  hydrochloric  has  no  action  on  uric  acid,  while  the  nitric 
dissolves  it  as  well  as  the  earthy  salt:  at  the  same  time  it  requires  a  much  larger 
addition  of  acid  to  produce  theone  effect  than  the  other.  Oxalate  of  lime  scarcely 
ever  exists  as  a  visible  sediment,  but  it  is  also  dissolved  by  the  stronger  acids. 
If  it  were  desirable  to  determine  by  chemical  reaction  whether  a  scanty  deposit, 
having  the  character  of  an  earthy  salt,  were  phosphate  or  oxalate,  we  should  test 
one  portion  with  acetic  acid,  which  dissolves  the  former  and  not  the  latter. 

The  crystalline  uric  acid  deposit  is  similarly  often  left  after  the  salts  are  dis- 
solved: its  solubility  on  the  addition  of  a  considerable  amount  of  nitric  acid  dis- 
tinguishes it  from  blood,  and  from  fine  sand,  which  hysterical  patients  occasionally 
mix  with  their  urine.  Its  general  characters  are  so  marked  that  there  is  no  real 
difficulty  in  recognising  it.  Sometimes  found  in  urine,  which  becomes  perfectly 
transparent  on  standing,  it  is  very  frequently  accompanied  by  a  cloud  of  mucus; 
and  it  may  be  seen  in  other  instances  mixed  with  blood:  in  either  case  the  urine 
will  not  become  transparent  when  boiled  with  acid,  although  the  uric  acid  itself 
may  disappear. 

Part  of  the  sediment  may  be  dissolved  by  heat  or  acid,  but  part  may  still  re- 
main, or  it  may  have  been  wholly  unaffected  by  either  reagent.  To  a  fresh  por- 
tion of  urine  liquor  potassre  is  added,  and  heat  applied:  under  all  circumstances  a 
precipitation  of  the  earthy  salts  takes  place,  aud  by  careful  boiling  these  may  be 


SEDIMENTS — MICROSCOPICAL    CHARACTERS.  355 

collected  into  a  mass,  which  floats  in  the  fluid,  leaving  the  remainder  perfectly 
transparent  when  the  opacity  has  been  caused  by  purulent  deposit.  If  the  quan- 
tity of  pus  be  not  sufficient  to  make  the  fluid  ropy,  a  few  drops  of  acid  are  allowed 
to  fall  on  the  aggregation  of  earthy  salts,  which  are  readily  dissipated ;  and  if  the 
alkali  have  dissolved  any  pus  or  other  albuminous  principle,  a  very  distinct  cloud 
is  formed  in  the  urine  iu  consequence  of  the  coagulation  of  albumen  by  the  acid. 
The  circumstance  of  a  whitish  deposit,  which  was  not  wholly  soluble  in  heat  and 
nitric  acid,  being  partly  dissolved  by  liquor  potassie  with  heat,  and  the  addition  of 
nitric  acid  to  this  solution  causing  the  remainder  to  disappear,  and  a  cloud  of  al- 
bumen to  form,  may  be  received  as  pretty  satisfactory  evidence  of  the  admixture 
of  pus. 

Nothing  has  been  said  of  cystine,  although  it  has  nearly  similar  relations  to 
chemical  tests,  simply  because  it  is  so  rare.  The  fact  of  its  being  a  fawn-coloured 
deposit,  and  yet  not  dissolving  by  heat  alone,  as  similarly  coloured  urates  do,  would 
necessarily  lead  to  further  inquiry;  purulent  deposits  are  invariably  white.  Uric 
acid  sand  is  also  dissolved  by  boiling  with  an  alkali;  but  this  can  give  rise  to  no 
confusion,  because  its  characters  are  so  striking. 

While  heating  the  urinary  sediment  we  have  also  to  observe 
whether,  as  the  temperature  rises,  the  fluid  first  becomes  transparent, 
and  then  a  fresh  cloud  subsequently  forms;  or -whether,  when  the 
opacity  is  not  removed  in  the  first  instance,  it  becomes  more  turbid 
as  the  application  of  heat  is  continued:  and,  further,  what  is  the 
effect  of  one  or  two  drops  of  acid  upon  this  new  precipitate. 

b.  Microscopical  appearances. — It  is  especially  important  for  the 
student  to  correct  by  the  microscope  the  conclusions  he  has  ar- 
rived at  from  chemical  analysis:  and  in  all  cases  of  doubt  its  aid 
is  most  valuable.  Almost  any  portion  of  urine  placed  in  the  field 
of  the  microscope  will  present  some  minute  objects  floating  about; 
but  it  is  better  to  let  it  rest  some  time,  and  then  to  take  a  drop 
from  the  bottom  of  the  vessel :  it  will  often  happen  that  the  micro- 
scope shows  that  there  is  a  tolerably  abundant  sediment  when  it  is 
scarcely  observed  with  the  naked  eye,  because  it  differs  so  little 
from  the  fluid  in  its  power  of  refracting  the  rays  of  light.  The 
student  need  never  perplex  himself  trying  to  make  out  shapeless 
objects,  but  should  confine  his  attention  to  a  few  of  the  more  dis- 
tinct organic  and  crystalline  formations. 

Among  the  organic  bodies  we  observe, — 

1.  Blood-globules:  these,  it  must  be  remembered,  are  not  often 
found  in  their  normal  form,  but  variously  altered  by  the  fluid  in 
which  they  float,  being  sometimes  unusually  flattened,  but  perhaps 
still  more  frequently  ruptured,  and  unequally  distended,  so  as  to 
assume  a  crescentic  or  a  somewhat  globular  form. 

2.  Pus  and  mucus-globules;  which  can  scarcely  be  distinguished 
from  each  other,  and  are  most  readily  known  by  their  relative  num- 
bers: a  few  solitary  globules  may  be  certainly  regarded  as  mucus, 
a  very  large  number  as  certainly  pus :  they  are  also  in  some  mea- 
sure distinguishable  by  the  circumstance  that  pus  globules  are  more 
decidedly  granular,  mucus  smoother  and  more  uniform. 

3.  Epithelium,  when  present,  would  determine  any  doubtful  glo- 
bules to  be  mucus  rather  than  pus.  One  or  two  scales  may  be  seen 
in  almost  any  specimen  of  urine,  and  they  are  only  of  consequence 


856  EXAMINATION    OF    THE    URINE. 

when  tolerably  abundant,  as  indicating  irritation  of  the  bladder  or 
urinary  passages.  Epithelium  is  generally  found  in  large  quantity 
in  the  mine  of  women,  being  derived  frpm  the  uterus  and  vagina: 
the  scales  of  this  variety  are  much  larger  than  those  which  come 
from  the  bladder. 

I.  Tubular  casts  are  found  in  cases  of  albuminuria:  of  late  some 
stress  has  been  laid  upon  whether  they  present  a  smooth,  homoge- 
neous, transparent  appearance,  or  whether  they  are  stuffed  with 
granular  matter,  as  indicating  two  distinct  conditions  of  kidney- 
disease;  equal  importance  has  been  attached  to  their  being  in  cer- 
tain cases  associated  with  oil  globules.  Independent  of  the  uncer- 
tainty attending  these  observations,  e.  g.,  globular  lithatcs  having 
been  unquestionably  mistaken  for  fat,  it  does  not  appear  that  the 
student  can  derive  any  useful  information  from  their  discrimination ; 
and  their  relations  seem  at  present  to  be  subjects  of  study  rather 
for  men  who  are  investigating  the  pathology  of  the  kidney,  than 
for  those  who  wish  to  turn  such   knowledge  to  a  practical  account. 

5.  Vibriones  may  often  be  seen  in  active  movement:  their  pre- 
sence is  not  connected  with  any  particular  forms  of  disease,  but 
merely  with  chemical  change  in  the  urine. 

G.  The  presence  of  spermatozoa  may  sometimes  throw  light  on 
an  otherwise  obscure  case. 

Among  crystalline  substances  we  observe, — 

1.  Oxalate  of  lime. — This  may  be  regarded  as  one  of  the  most 
important;  not  so  much  from  the  intrinsic  value  of  the  observation, 
as  from  the  circumstance  that  we  have  no  other  means  of  detecting 
its  presence  with  certainty.  It  occurs  generally  in  octohedral 
crystals  ;  occasionally  we  meet  with  some  very  short  square  prisms 
of  uric  acid,  which  closely  resemble  the  oxalate  of  lime ;  but  with 
care  this  need  never  be  any  source  of  fallacy.  The  planes  of  re- 
fracted light  crossing  the  square  surface  diagonally,  and  disappear- 
ing and  reappearing  as  the  focus  is  altered,  are  extremely  charac- 
teristic, and  never  seen  under  other  circumstances. 

2.  Uric  acid. — In  combination  with  alkali  the  urates  are  chiefly 
seen  under  the  microscope  as  amorphous  granular  matter,  or  as- 
suming a  variety  of  irregular  rounded  shapes.  The  observation  that 
alon^  -with  this  deposit  there  are  some  defined  crystals  of  uric  acid 
is  of  considerable  value  in  treatment;  and  this  the  microscope  can 
alone  determine  with  certainty;  the  lozenge-shaped  crystals  and 
square  prisms  of  the  acid  being  quite  distinctive.  The  same  obser- 
vation will  immediately  solve  any  doubt  as  to  the  true  nature  of  the 
sabulous  deposit,  which,  in  its  uncombined  form,  lithic  acid  usually 
presents. 

3.  Triple  phosphate. — The  chemical  test  is  of  itself  quite  suffi- 
cient to  distinguish  the  presence  of  earthy  salts ;  and  the  most  com- 
mon of  these,  the  phosphate  of  lime  is  rarely  found  in  a  crystallized 
form ;  like  the  urates,  the  phosphates  are  often  seen  only  as  granu- 
lar matter.     The  three-sided  prisms  with  bevelled  ends,  which  cha- 


SEDIMENTS — MICROSCOPICAL    CHARACTERS.       357 

racterize  the  triple  phosphate,  are  not  liable  to  be  confounded  with 
any  other  crystals.  They  indicate  the  presence  of  an  excess  of 
free  ammonia,  and  therefore  the  probability  of  partial  decomposi- 
tion of  the  urine ;  but  this  rule  must  not  be  regarded  as  absolute, 
for  cases  occasionally  occur  in  which  it  is  caused  by  the  secretion  of 
alkaline  urine. 

These  are  the  most  important  of  the  objects  which  microscopic  examination  re- 
veals. The  list  might  be  considerably  added  to,  and  the  student,  in  learning  the 
microscope,  may  often  usefully  employ  his  time  in  unriddling  some  of  the  more 
complex  or  more  rare  phenomena,  detailed  in  the  various  treatises  on  this  subject, 
because  by  such  means  he  acquires  familiarity  with  the  use  of  the  instrument; 
those  just  described  are  necessary  for  the  purposes  of  diagnosis.  If  the  chemical 
tests  be  rightly  applied,  pretty  nearly  all  the  facts  regarding  the  simpler  forms  of 
sediments  may  be  ascertained  without  the  use  of  the  microscope.  It  is  in  the 
complex  cases,  where  there  is  any  admixture,  that  its  value  becomes  so  great  in 
discriminating  the  different  objects,  and  showing  the  true  character  of  each,  when 
several  distinct  sets  of  chemical  experiments  might  have  been  needed  to  accom- 
plish the  same  end.  It  is  particularly  useful  when  the  urine  is  generally  opaque, 
and  the  effects  of  chemical  reagents  on  the  sediment  are  less  distinct.  The  pre- 
sence or  absence  of  blood-globules  in  the  sediment,  when  the  urine  is  dark  co- 
loured, a  large  amount  of  epithelium,  or  some-pus  globules,  when  it  is  milky,  and 
the  absence  of  any  abnormal  deposit  when  heat,  acid,  and  alkali  have  alike  failed 
to  remove  the  haze  after  partial  decomposition  has  begun,  are  each  of  great  value 
in  confirmation  of  the  chemical  analysis.  But,  on  the  other  hand,  heat  and  acid 
will  distinguish  in  a  moment  between  the  lithates  and  the  phosphates  in  their 
amorphous  condition, — a  conclusion  which  at  best  can  only  be  guessed  at  by  the 
employment  of  the  microscope. 

The  microscope  does  not  afford  much  assistance  in  determining  the  source  of 
hemorrhage  when  blood  is  present.  Tubular  casts,  mixed  with  blood-globules, 
would  show  that  passive  congestion  of  the  kidney  accompanied  the  haiinaturia : 
and  this  would  be  coincident  with  an  excess  of  albumen  in  the  urine.  Crystals  of 
uric  acid  may  lead  to  the  suspicion  of  the  existence  of  a  calculus  as  its  cause:  but 
it  must  be  remembered  that  they  are  constantly  found  in  the  hematuria  of  scarla- 
tinal dropsy.  In  fungoid  disease  of  the  bladder,  the  compound  cells  of  cancerous 
growth,  and  in  chronic  ulceration,  pus-cells  accompany  the  blood-globules  when 
the  hemorrhage  is  from  the  bladder.  The  changes  in  form  which  they  undergo 
are  dependent  equally  upon  the  chemical  relations  of  the  uriue,  and  the  period 
during  which  they  have  remained  in  it. 

Pus  in  small  quantity,  and  mucus  in  excess,  whether  from  the  bladder  or,  in 
females,  from  the  vagina,  are  each  of  them  sources  of  perplexity  which  the  micro- 
scope readily  explains.  It  is  of  very  little  consequence  which  name  is  applied,  as 
there  is  evidently  no  clear  line  of  demarkation  between  them :  very  large  epithelium 
scales  serve  to  show  that  the  vagina  is  the  source  of  the  secretion;  of  a  smaller 
size,  their  presence  in  unusual  number  might  be  taken  as  evidence  that  the  ac- 
companying globules  came  from  the  bladder,  and  not  the  kidney,  and  were  rather 
mucus  than  pus.  When  the  globules  are  very  numerous,  we  cease  to  call  them 
mucus  under  any  circumstances;  an  irregular  serrated  edge  seems  to  belong 
especially  to  scrofulous  pus;  little  agglomerations  of  globules  show  that  there  is 
a  tendency  to  fusion,  the  urine  is  scarcely  acid,  and  the  source  of  the  secretion  is 
very  probably  the  bladder.  Mucus  and  bladder-epithelium  are  chiefly  found  when 
crystals  of  uric  acid  or  oxalate  of  lime  are  present  in  the  urine,  which  no  doubt 
act  as  irritants  on  the  mucous  membrane. 

Tubular  casts  should  always  be  looked  for  by  the  student,  because  they  teach 
him  when  albumen  is  dependent  on  degeneration  of  the  kidney,  and  thus  give  him 
clearer  notions  of  its  origin,  and  of  the  cases  in  which  its  presence  is  caused  by 
other  circumstauces:  but  it  would  be  very  rash  to  say  there  was  no  renal  disease 
simply  because  casts  were  not  seen. 

Vibrioses  and  spermatozoa  are  both  causes  of  opalescence  which  the  microscope 


358  EXAMINATION    OF   THE     URINE. 

can  alone  clear  up.  Chemically,  it  may  bo  determined  that  the  condition  is  not 
one  of  much  importance  with  reference  to  disease  of  the  kidney;  but  spermatozoa 
are  of  considerable  moment  with  reference  to  the  general  health  of  the  patient. 

Oxalate  of  lime,  as  a  discovery  of  late  years,  received  at  one  time  a  greater 
share  of  attention  than  it  deserved:  its  presence  is  by  no  means  rare,  and  is  not 
in  any  way  connected  with  perverted  function  or  diseased  action  of  the  kidney. 
It  is  not  uncommonly  found  in  a  dumb-bell  shaped  crystal;  but  the  student  ought 
not  to  take  this  form  as  characteristic  of  oxalate  of  lime,  unless  the  ordinary  oc- 
dra  be  also  present. 

Uric  acid,  when  found  in  the  urine  in  crystals,  seems  to  show  a  different  con- 
dition of  health  from  that  in  which  it  is  found  ouly  in  combination  with  alkali,  and 
hence  the  importance  of  the  observation.  Probably,  when  the  urates  appear  as 
semi-crystalline  rounded  masses,  they  show  an  approach  to  the  same  diathesis; 
but  at  present  we  cannot  assign  any  very  satisfactory  reason  why  this  substance 
appears  sometimes  in  the  crj-stalline,  and  sometimes  in  the  amorphous  form. — 
uncombined,  or  as  a  compound  body.  It  is  worth  remembering  that  the  globular 
urates  occasionally  possess  so  high  a  refractive  power  as  to  have  been  mistaken 
for  oil-globules. 

It  is  equally  difficult  to  say  why  the  phosphate  of  lime  is  sometimes  crystallized, 
sometimes  amorphous:  the  form  of  its  crystals  is  long  and  acicular,  and,  when 
present,  there  can  be  no  doubt  that  the  urine  was  passed  in  an  alkaline  state,  and 
that  the  alkalescence  was  not  derived  from  excess  of  ammonia;  but,  on  the  other 
hand,  such  a  condition  of  urine  does  not  necessarily  imply  crystalline  phosphate. 
Triple  phosphate,  in  a  large  proportion  of  cases,  follows  decomposition  of  the  urine: 
bat  it  is  recorded  as  having  occurred  when  there  was  no  trace  of  decomposition, 
and  the  alkalescence  of  the  urine  depended  only  on  conditions  of  depressed  vitality. 
It  is  one  of  those  objects  which  from  its  unmistakeable  appearance  is  of  great  use 
to  the  learner,  because  it  never  occurs  along  with  a  deposit  of  urates,  but  always 
with  the  phosphate  of  lime. 

§  5.  Urine  free  from  Deposit. — We  next  proceed  to  apply  our 
chemical  tests  to  the  urine  which  has  been  decanted  off  the  sedi- 
ment, or  to  urine  which  has  not  let  fall  any  appreciable  deposit. 
Two  abnormal  ingredients  occupy  the  first  place,  because  they  are 
constantly  found  in  certain  conditions  of  disease,  and,  as  they  are 
freely  soluble,  give  no  other  direct  indications  of  their  presence; 
and  a  few  words  must  be  added  on  excess  of  urea,  which  also  never 
occurs  as  sediment. 

a.  Albumen. — The  means  resorted  to  for  ascertaining  the  pre- 
sence of  albumen  are  heat  and  nitric  acid,  each  of  which  has  the 
property  of  coagulating  it;  and  in  certain  cases  the  extraordinary 
amount  of  the  precipitate  formed  by  either,  leaves  no  possible  doubt 
as  to  the  fact.  It  is  only  where  the  quantity  is  small  that  there 
is  any  difficulty  in  coming  to  a  determination  upon  the  subject,  and 
especially  when  the  urine  is  not  quite  transparent.  In  speaking  of 
this  opacity  (§  3,)  it  was  shown  to  be  chiefly  produced  by  an  ad- 
mixture of  pus  or  mucus,  or  an  effusion  of  blood ;  and  if  these  cir- 
cumstances can  be  traced  to  disease  of  the  kidney,  it  is  evident 
that  the  accompanying  albumen  will  be  in  considerable  amount  and 
the  reaction  decided.  When  therefore  any  doubt  exists,  the  very 
inconclusiveness  of  the  experiment  may,  to  a  certain  extent,  be 
regarded  as  a  proof  that  the  kidneys  are  not  diseased. 

The  readiest  method  for  the  detection  of  albumen  is  certainly 
that  of  pouring  from  half  a  drachm  to  a  drachm  of  nitric  acid  to 


ALBUMEN.  359 

the  bottom  of  a  precipitate  glass  containing  the  urine  to  be  ex- 
amined. This  can  easily  be  effected  by  allowing  it  to  run  (Jown  the 
side  of  the  glass;  and  if  the  fluids  do  not  intermingle,  coagulation 
of  the  albumen  takes  place  only  at  their  line  of  junction,  and  may 
be  observed  even  when  exceedingly  faint,  by  varying  the  position 
of  the  glass  with  reference  to  the  light,  and  observing  the  effect  of 
its  transmission'and  reflection.  The  chief  source  of  fallacy  is  the 
fact  that  nitric  acid  has  the  power  of  precipitating  an  excess  of 
urate  of  ammonia  when  held  in  solution  by  any  unusual  circum- 
stance. A  few  experiments  will  better  teach  the  different  appear- 
ance of  the  two  precipitates  than  any  description;  but  if  any  doubt 
remain,  a  small  quantity  of  the  urine  may  be  boiled  after  only  so 
much  acid  has  been  added  as  is  necessary  to  produce  the  precipita- 
tion ;  the  cloud  will  wholly  disappear  if  it  consist  only  of  the  lithates. 
In  employing  heat  as  a  test  of  the  presence  of  albumen,  it  is  to 
be  borne  in  mind  that  heat  develops  chemical  action,  and  may 
produce  a  precipitate  of  phosphate  of  lime,  and  that  the  coagula- 
tion of  the  albumen  may  be  prevented  either  by  the  urine  being 
alkaline'or  by  a  single  drop  of  strong  acid  being  added  to  a  neutral 
specimen.  Both  difficulties  are  best  avoided  by  acidulating  the 
urine  first  with  acetic  acid;  and  then,  if  the  upper  part  of  the 
urine  in  the  test-tube  be  boiled,  while  the  lower  part  is  only  gently 
heated,  the  contrast  of  opacity  above  and  transparence  below  is 
often  sufficient  to  indicate  the  presence  of  an  exceedingly  small 
quantity  of  albumen. 

In  the  first  of  these  two  methods  we  have  the  advantage  of  being  able  to  say 
with  considerable  confidence  whether,  when  the  urine  is  opaque,  this  is  increased 
at  the  junction  of  the  two  fluids:  in  cases  where  there  is  only  a  trace  of  albumen, 
even  if  the  urine  be  perfectly  transparent,  the  haze  produced  by  its  coagulation  is 
more  easily  perceived  in  this  experiment  than  when  boiled  in  a  test-tube.  In 
either  case  it  is  difficult  to  apply  the  further  test  of  heat,  because  the  precipitate 
formed  by  the  acid  becomes  less  perceptible  when  transfused  through  the  fluid, 
and  it  may,  consequently,  seem  to  disappear  with  heat;  and  we  are  uncertain 
whether  it  be  soluble  or  insoluble — whether  urate  of  ammonia  or  albumen  had 
been  thrown  down  by  the  acid.  Other  circumstances,  however,  sometimes  serve 
to  determine  that  the  haze  is  not  caused  by  precipitation  of  the  urates :  if  a  de- 
posit have  already  spontaneously  occurred,  or  if  the  urine  be  naturally  very  acid 
without  deposit,  no  addition  of  nitric  acid  will  precipitate  the  urates  from  the  clear 
urine:  and  if  the  urine  be  pale,  and  of  low  specific  gravity,  it  is  impossible  by  such 
means  to  render  these  salts  insoluble  in  the  excess  of  water  which  exists:  in  any 
of  these  cases  we  may  therefore  assume  that  the  haze  is  albumen. 

We  must  be  on  our  guard  in  employing  this  test  with  opaque  urine,  lest  the  pa- 
tient be  at  the  time  suffering  from  gonorrhoea,  and  employing  some  of  the  resinous 
remedies,  which  are  eliminated  by  the  kidney,  and  are  decomposed  by  nitric  acid 
in  the  urine.  This  precipitate  is  also  insoluble  by  heat,  but  may  be  distinguished 
from  albumen  by  its  amount  being  considerable,  and  yet  no  coagulation  occurring 
when  heat  alone  is  used,  or  used  in  conjunction  with  one  of  the  weaker  acids.  Oc- 
casionally it  may  be  of  service,  when  the  urine  is  opaque,  to  boil  it  with  alkali,  as 
mentioned  in  speaking  of  the  chemical  relations  of  pus  {\  4,  a  4;)  the  whole  of  the 
fluid  may  thus  be  rendered  transparent,  with  the  exception  of  the  mass  of  phos- 
phate floating  up  and  down,  and  an  opportunity  afforded  of  ascertaining,  by  the 
addition  of  acid,  what  amount  of  precipitation  occurs.  All  pus  has  a  certain  quan- 
tity of  albumen  necessarily  associated  with  it;  but  it  is  very  much  greater  when 
the  discharge  is  from  the  kidney  than  when  it  comes  only  from  the  bladder. 


I  EX  AM  IN  ATI  ON    OF    THE    URINE. 

'l'ln-  heat-test  for  albumen  is  most  certain  when  tlic  urine  is  perfectly  limpid,  and 
decidedly  acid.  Opacity  can  only  be  removed  by  filtering;  ami  the  process  i-  just 
sufficiently  troublesome  never  to  be  practised.  The  nearest  approximation  to 
truth,  in  applying  heat  in  such  cases,  is  to  compare  the  urine  in  the  test-tube,  after 
being  boiled  with  another  portion  of  the  same  fluid  in  a  second  tube  of  the  same 

In  using  the  stronger  acids,  as  is  commonly  done  when  the  urine  is  alkaline  or 
neutral,  we  encounter  some  difficulties  and  sources  of  error.  •  If  only  a  drop  of 
.  be  added  before  the  urine  is  boiled  it  may  pievent  the  precipitation  of  the  al- 
bumen altogether;  if  more  be  used,  the  albumen  is  apt  to  be  coagulated,  and  it  is 
no  longer  the  heat-test,  but  the  acid-test.  If,  again,  the  urine  be  boiled  without 
ipitate  of  phosphate  is  likely  to  be  formed  if  the  urine  be  alkaline;  and 
though  this  may  be  removed  by  a  drop  or  two  of  acid,  the  further  addition  of  acid 
may  not  afford  such  distinct  evidence  of  the  presence  of  albumen  when  the  tem- 
perature is  raised  to  the  boiling  point,  and  it  may  have  to  stand  some  time  before 
the  precipitation  can  be  observed. 

In  one  or  two  instances  I  have  seemed  to  get  more  precise  results  in  doubtful 
cases  by  warming  the  urine,  so  as  to  prevent  the  precipitation  of  the  urates,  with- 
out coagulating  the  albumen,  and  then  applying  the  nitric  acid  test  in  a  precipi- 
tate-glass, as  already  mentioned. 

When  the  results  of  the  examination  are  at  all  unsatisfactory, 
very  explicit  directions  should  be  given  to  the  patient  to  preserve 
any  portion  of  the  urine  that  is  transparent  when  passed,  in  a  per- 
fectly clean  vessel:  not  uncommonly  all  the  difficulties  are  caused 
by  some  accidental  admixture,  and  in  all  circumstances,  a  second 
analysis  often  throws  much  light  upon  the  previous  one.  In  other 
instances,  when  the  trace  of  albumen  is  but  slight,  it  is  very  neces- 
sary for  correct  diagnosis  to  make  a  second  or  a  third  examination, 
at  intervals;  because  the  casual  occurrence  of  albumen  in  small 
quantity  is  generally  not  a  matter  of  very  great  importance,  and  if 
urine  passed  at  other  times  be  distinctly  free  from  it,  there  is  every 
probability  that  it  is  not  caused  by  organic  change.  Further,  it 
may  be  added  that,  when  any  suspicion  occurs  to  the  mind  of  the 
possible  existence  of  albuminuria,  one  examination  alone,  however 
exactly  performed,  and  however  explicit  in  its  results,  is  not  suffi- 
cient, because,  as  the  casual  presence  of  albumen  is  no  certain 
proof  of  the  existence  of  organic  change,  so  the  urine  may  be 
casually  free  from  it,  in  any  stage  of  disease  of  the  kidney. 

h.  Sugar. — In  considering  the  general  symptoms  of  disease  in 
their  relation  to  the  urinary  organs,  in  the  succeeding  chapter,  the 
aggregate  of  symptoms  in  a  case  of  diabetes  will  be  found  of  such 
a  character  as  to  mark  out  very  clearly  the  nature  of  the  disease; 
yet  it  is  needful  to  be  able  to  pronounce  positively  in  any  given  case 
whether  sugar  be  present  in  the  urine.  In  the  greater  number  of 
cases,  the  changes  produced,  when  diabetic  urine  is  boiled  with  an 
equal  quantity  of  liquor  potassre,  are  quite  sufficient  for  the  pur- 
pose. The  urine  becomes  gradually  of  a  deep  yellow,  which  passes 
into  brown,  and  then  assumes  a  crimson  or  ruby  appearance  by 
transmitted  light,  exhaling  an  odour  of  burnt  sugar  or  caramel. 
This  sequence  of  changes  cannot  be  misinterpreted  by  any  one  who 
has  performed  the  experiment  two  or  three  times;  but  it  is  open 


UBEA.  361 

to  fallacy  if  one  who  is  not  familiar  with  the  test  trust  to  it  alone, 
and  it  may  fail  to  detect  a  very  minute  quantity  of  sugar. 

Greater  certainty  can  be  attained  by  the  action  of  sugar  upon 
salts  of  copper,  and  students  ought  on  all  occasions  to  familiarize 
themselves  with  it.  A  few  drops  of  a  strong  solution  of  sulphate 
of  copper  are  added  to  the  urine,  and  then  a  considerable  quan- 
tity of  liquor  potassre :  the  first  portion  of  the  alkali  causes  preci- 
pitation, its  further  addition  dissolves  the  precipitate  so  formed :  heat 
is  now  applied,  and,  when  the  temperature  rises  to  a  certain  point, 
a  yellow  precipitate  is  rapidly  formed.  The  accuracy  of  the  test 
depends  upon  the  two  circumstances  coinciding,  that  the  precipitate 
has  an  evident  tinge  of  yellow,  and  that  it  is  formed  with  rapidity. 
A  variety  of  chemical  changes  may  precipitate  the  copper  on  pro- 
longed boiling,  but  its  colour  is  usually  tawny  or  brown;  and  prac- 
tically it  is  found  that  the  only  condition  which  gives  rise  to  the 
rapid  formation  of  a  yellow  precipitate  is  the  presence  of  diabetic 
or  grape-sugar. 

The  specific  gravity  of  diabetic  urine  is  invariably  high,  although 
the  quantity  passed  be  much  greater  than  in  health:  and  while  it  is 
true  that  the  absolute  amount  of  the  sugar  dissolved  in  the  fluid  is 
one  of  the  causes  of  its  increased  density,  it  is  not  the  only  one, 
and  therefore  the  specific  gravity  cannot  be  taken  as  a  measure  of 
the  saccharine  matter  present.  In  no  other  condition  of  disease  is 
the  density  so  great;  and  yet  there  is  rarely  any  deposit,  the  urine 
being  generally  pale,  straw-coloured,  and  very  often  having  a  sort 
of  oiliness  in  being  poured  from  one  vessel  to  another. 

c.  Urea. — When  the  specific  gravity  of  the  clear  urine  is  above 
the  normal  standard,  whether  there  be  any  deposit  or  not,  and  we 
have  ascertained  that  no  sugar  is  present,  the  conclusion  is  unavoid- 
able that  it  is  impregnated  with  an  unusually  large  amount  of  those 
soluble  principles  which  give  to  urine  its  ordinary  characteristic 
properties,  derived  from  metamorphosis  of  tissue ;  the  most  import- 
ant of  which  is  urea.  The  uric  acid  salts  we  have  seen  may  be 
held  in  solution  by  an  excess  of  alkali,  and  are  precipitated  by  nitric 
acid;  urea  is  not  so  precipitated:  if  no  change  occur  on  the  addi- 
tion of  a  small  quantity  of  acid,  a  little  urine  may  be  poured  into 
a  flat  glass  (a  watch-glass.)  and  about  half  its  bulk  of  strong  acid 
added  to  the  fluid,  when,  if  urea  be  present  in  considerable  excess, 
feathery  crystals  of  nitrate  of  urea  will  form.  To  produce  this 
effect  its  amount  must  be  very  considerable,  so  that  even  when  we 
do  not  obtain  it,  we  are  not  justified  in  asserting  that  no  excess  of 
urea  is  present:  when  the  urine  is  deep-coloured,  its  density  great, 
and  its  peculiar  odour  well  marked,  there  can  be  no  doubt  of  the 
fact  that  those  principles  among  which  urea  holds  a  first  place  are 
secreted  in  large  quantity,  and  treatment  must  be  guided  by  this 
assurance. 

Occasionally  the  urea  is  converted  into  carbonate  of  ammonia  by 
some  catalytic  action,  which  probably  commences  before  the  urine 


362  EXAMINATION    OF   THE    URINE. 

is  passed,  but  is  greatly  promoted  by  the  action  of  beat.  When 
the  urine  is  boiled  in  such  a  case,  the  amount  of  earthy  salts  thrown 
down  is  generally  considerable,  and  on  the  addition  of  acid  the 
precipitate  is  dissolved,  while  effervescence  takes  place  from  decom- 
position of  the  carbonate  of  ammonia.  This  actio"h  cannot  be  re- 
garded as  any  evidence  of  an  excess  of  urea. 

The  following  table  represents  most  of  the  chemical  relations  explained  in  the 
preceding  pages: — 

A.  Peposits: — 

1.  Soluble  by  heat Urates. 

2.  Insoluble  by  heat: 

a.  Soluble  in  acetic  acid Phosphates. 

b.  Soluble  in  nitric  acid ,.'.    <l   . ,' 

|  uric  acid. 

c.  Soluble  in  alkali ]  7-  • '      •■, 

(  Uric  acid. 

b.  Clear  urine  : — 

1.  Precipitate  produced  by  heat: 

a.  Soluble  in  acid Earthy  salts. 

b.  Insoluble  in  acid Albumen. 

2.  Precipitate  produced  by  acid: 

a.  Soluble  by  heat      .     .     - Urates. 

b.  Insoluble  by  heat Albumen. 

3.  Precipitate  produced  by  alkali Earthy  salts. 

c.  Urine  effervescing  with  heat  and  acid Urea  converted  into 

carbonate  of  am- 
monia. 
D.  Urine  becoming  reddish-brown  with  heat  and  liquor 

potasste Sugar. 


363 


CHAPTER  XXXI. 

DISEASES    OF   THE    URINARY   ORGANS. 

§  1,  Nephritis  and  Nephralgia — after  Exposure— from  Scarlatina 
—from  Calculus — §  2,  Abscess — its  modes  of  Discharge — Pus  in 
the  Urine — §  3,  Ischuria — distinguished  from  Retention — §  4, 
Albuminuria — its  Origin — Symptoms — Characters  of  the  Urine 
— with  Dropsy — ivithout  Dropsy — Bloody  Urine — §  5,  Diuresis 
— §  6,  Cystitis — Calculus — Ropy  Mucus—  §  7,  Diabetes — §  8, 
Disordered  Functions — Excess  or  Deficiency  of  Water — Depo- 
sits—  Uric  Acid — Phosphates  —  Acidity — Urea — Oxalate  of 
Lime — Relations  of  Disease  of  the  Kidney. 

In  proceeding  to  apply  the  inferences  deducible  from  the  condi- 
tion of  the  urine  to  the  diagnosis  of  diseases  of  the  urinary  organs, 
reference  must  also  be  made  to  those  changes  which  are  due  to  dis- 
turbing influences  acting  through  the  general  circulation,  and  are 
in  no  way  connected  with  actual  lesion  of  the  kidney.  It  is  almost 
impossible  to  get  at  the  early  history  of  the  diseases  of  these  organs, 
because  it  is  only  when  some  very  remarkable  change  in  the  cha- 
racter of  the  secretion  takes  place,  or  when  some  secondary  affec- 
tion is  developed,  that  the  patient  seeks  for  advice,  or  is  even  con- 
scious that  any  thing  is  wrong.  This  is  not  less  true  of  the  acute 
than  of  the  chronic  affections ;  but  as  the  progress  of  the  former  is 
more  rapid,  we  are  commonly  able  to  trace  the  history  backwards 
to  what  may  be  justly  considered  its  starting-point. 

§  1.  Nephritis  and  Nephralgia. — The  secretion  of  urine  is  more 
or  less  suppressed  in  nephritis,  and  as  a  consequence  anasarca  ra- 
pidly ensues ;  but  the  patient  thinks  nothing  of  the  diminished  flow 
of  urine,  and  is  perhaps  greatly  astonished  when  dropsy  comes  on. 
Frequently  and  very  justly  ascribed  to  having  caught  cold,  it  is  very 
evidently  associated  with  disturbed  cutaneous  action;  it  sometimes 
occurs  in  a  perfectly  healthy  person  after  very  severe  exposure; 
more  commonly,  however,  there  is  pre-existing  disease  of  the  kid- 
ney, or  it  follows  a3  a  specific  action,  at  a  pretty  definite  interval, 
upon  an  attack  of  scarlatina;  in  the  latter  case  we  may  generally 
trace  some  slight  exposure,  but  it  is  alleged  by  some  observers  that 
it  may  be  the  direct  effect  of  the  scarlatinal  poison  without  any  such 
exciting  cause. 

It  commences  with  febrile  disturbance,  and  there  is  often  deep 
aching  pain  in  the  back :  the  urine  is  scanty,  loaded,  deep-coloured,  of 
high  specific  gravity  and  albuminous:  blood  is  sometimes  mixed 
with  it,  as  a  consequence  of  congestion;  but  this  does  not  appear 


864  DISEASES   OF    THE    URINARY   ORGANS. 

early  when  the  kidneys  are  previously  healthy.  Total  suppression 
of  urine  is  not  commonly  the  result  of  nephritis  in  a  healthy  kid- 
ney, and  when  that  event  occurs,  we  may  generally  conclude  that 
disease  of  long  standing  is  present,  however  acute  the  attack  may 
Otherwise  appear.  A  common  impression  prevails  that  an  attack 
of  nephritis  lays  the  foundation  for  subsequent  chronic  disease;  but 
there  is  no  evidence  to  prove  this  relation,  and  it  ought  not  to  be 
assumed  until  we  know  that  among  a  given  number  of  patients  who 
have  had  scarlatinal  dropsy  subsequent  disease  is  more  common 
than  among  a  similar  number  who  have  never  had  scarlatina  at  all; 
the  hypothesis,  however,  is  not  without  probability. 

Another  form  of  nephritis  is  excited  by  local  causes,  whether  in 
consequence  of  external  injury  or  the  presence  of  a  calculus  in  the 
kidney,  when  it  is  preceded  by  nephralgia.  These  two  causes  of 
nephritis  have  this  effect  in  common,  that  the  attack  sometimes  ter- 
minates in  abscess.  Nephralgia,  in  so  far  as  it  may  be  distinguished" 
from  nephritis,  expresses  the  pain  attending  the  affection  in  its 
early  stage ;  and  in  proportion  as  the  pain  is  severe,  we  may  con- 
clude that  it  is  due  to  irritation  rather  than  to  inflammation.  We 
cannot  go  back  to  the  date  of  the  formation  of  a  calculus,  but  Ave 
can  sometimes  discover  in  a  strain  or  a  sudden  jerk  of  the  body  the 
time  when  it  was  displaced.  Very  soon  after,  severe  pain  is  felt  on 
one  side  of  the  loins,  shooting  down  to  the  groin  and  inside  of  the 
thigh,  exciting  sympathetic  pain  and  retraction  of  the  testicle, 
or  encircling  the  abdomen,  and  passing  round  as  far  as  the  umbili- 
cus ;  the  severity  of  the  pain  is  sometimes  so  great  as  to  produce 
nausea  and  vomiting:  the  urine  may  be  blood-stained,  and  is  always 
passed  with  unusual  frequency.  After  a  time  the  calculus  tra- 
verses the  ureter  and  passes  into  the  bladder,  or  falls  back  again 
into  its  former  position,  and  the  pain  ceases.  The  patient  may  suf- 
fer only  from  the  irritation,  and  no  febrile  disturbance  ensue;  or 
inflammatory  action  may  supervene  in  the  affected  kidney,  when 
the  pain  persists  and  assumes  the  character  of  a  dull  aching  sensa- 
tion. 

Nephralgia  is  apt  to  be  confounded  with  colic;  and  as  we  have  seen  colic  pass 
into  enteritis,  so  the  nephritis  which  follows  is  liable  to  be  confounded  with  in- 
flammation of  the  bowels.  The  presence  of  sympathetic  affection  of  the  testicle, 
or  the  appearance  of  blood  in  the  urine,  would  be  sufficient  to  prevent  any  mis- 
take in  diagnosis;  but  these  are  often  absent,  and  dysuria  is  a  common  effect  of 
inflammation  of  the  bowels:  we  have,  then,  no  better  guide  than  the  history  of  its 
commencement  on  one  side  of  the  loins,  and  not  in  the  abdomen. 

Rheumatic  affections  may  also  be  confounded  with  nephralgia;  but,  apart  from 
the  suddenness  of  the  incursion,  and  the  constancy  and  severity  of  the  pain,  when 
the  kidney  is  affected,  they  may  be  distinguished  by  their  more  general  distribution, 
and  especially  by  the  circumstance,  that  the  pain  of  a  rheumatic  affection  is  only 
felt  on  moving,  or  at  least  is  very  greatly  aggravated  by  it. 

Sometimes  we  have  reason  to  believe  that  an  attack  of  nephralgia  has  nothing 
to  do  with  calculus  at  all,  but  is  merely  a  form  of  gout,  when  the  bowels  are 
loaded,  and  the  urine  secreted  is  highly  acid  and  irritating:  in  such  circumstances 
there  may  be  no  unusual  frequency  in  the  calls  to  empty  the  bladder,  as  the  se- 
cretion is  scanty,  and  the  irritation  of  the  kidney  less  intense. 


ABSCESS.  365 

§  2.  Abscess. — Sometimes  directly  traceable  to  an  attack  of  ne- 
phritis with  a  well-marked  history,  this  condition  of  the  kidney  is 
not  unfrequently  met  with  in  practice,  without  any  distinct  precur- 
sory symptoms :   no  doubt  there  must  be  some  degree  of  inflamma- 
tion before  pus  is  formed,  but  it  is  to  be  remembered  that  the  in- 
flammation is  often  of  the  strumous  kind,  and  then  the  evidence  of 
its  existence  is  necessarily  obscure.     In  either  case  the  pus  may 
make  its  way  externally,  through  the  loins,  or  may  be  discharged 
by  the  bowels,  or  be  voided  in  the  urine.     The  first  of  these  termi- 
nations is  to  be  recognised  by  the  position  and  size  of  the  swelling 
which  accompanies  it;  a  small  abscess  in  the  loins  leads  us  to  in- 
quire after  previous  attacks  of  nephralgia,  or  to  look  for  the  pre- 
sence of  albumen  in  the  urine;  a  larger  one  is  much  more  probably 
connected  with  disease  of  bone :  it  is  a  mistake  to  suppose  that  the 
pus  discharged  by  an  abscess  of  the  kidney  has  any  urinous  odour. 
In  the  second  form,  the  diagnosis  may  be  aided  by  calculi  being 
passed  by  the  rectum  along  with  the  pus:  if  the  history  of  the  case 
show  that  affection  of  the  kidney  had  existed  prior  to  the  appearance 
of  pus  in  the  stools,  and  there  be  no  indication  of  ulceration  of  the 
mucous  membrane  of  the  intestine,  it  is  highly  probable  that  it  pro- 
ceeds from  abscess  of  the  kidney.    When  pus  forms  in  consequence 
of  local  peritonitis,  there  is  very  generally  a  history  of  pain  some- 
where or  other  to  point  out  the  locality  in  which  the  inflammation 
had  been  going  on,  and  we  are  left  to  judge  from  probabilities  only, 
when  there  is  no  such  history  obtained. 

The  third  mode  of  discharge  is  the  most  common,  especially  in 
the  strumous  abscess.  The  attention  of  the  patient  is  first  arrested 
by  the  frequency  of  the  calls  to  empty  the  bladder:  the  total  quan- 
tity of  the  urine  in  the  twenty-four  hours  is  not  increased,  and  it  is 
turbid  when  passed,  depositing  a  white  sediment  on  standing.  It 
is  acid,  and  it  remains  slightly  opaque;  the  sediment  is  not  dissolved 
by  heat  or  acid,  but,  on  the  contrary,  both  of  these  reagents  in- 
crease the  turbidity,  and  the  decanted  fluid  gives  a  distinct  precipi- 
tate of  albumen.  The  sediment  is  in  great  part  dissolved^  by  boil- 
ing with  alkali,  and  the  fluid  becomes  ropy;  under  the  microscope 
abundant  globules  of  pus  are  seen.  If  these  characters  are  per- 
manent, we  may  be  certain  that  we  have  to  do  either  with  abscess 
of  the  kidney,  or  with  that  form  of  nephritis  which  gives  rise  to  sup- 
puration in  the  calyx, — pyelitis,  as  it  is  called:  and  I  do  not  know 
that  in  any  case  we  can  positively  affirm  which  of  the  two  is  present. 
Some  idea  of  its  nature  may  be  gained  from  the  relative  amount  of 
the  pus,  and  still  more  from  the  persistence  of  the  disease. 

Catarrh  of  the  bladder  (§  6)  is  at  times  liable  to  present  similar  features;  but 
there  are  two  grand  distinctions,  which  must  ever  be  borne  in  mind.  When  the 
suppuration  takes  place  in  the  kidney,  the  urine  continues  acid,  and  is  not  am- 
moniacal  when  passed,  and  the  pus  itself  remains  unchanged,  and  has  not  become 
ropy  or  mixed  with  phosphates;  the  triple  phosphate  especially,  which  is  so  com- 
mon in  cystitis,  is  never  seen  in  sueh  circumstances:  still  more,  in  consequence  of 


3GG  DISEASES    OF    THE    URINARY   ORGANS. 

the  disease  of  the  kidney,  the  urine  is  albuminous  in  a  much  greater  degree  than 
can  be  attributed  merely  to  the  amount  of  albumen  contained  in  the  liquor  puris 
which  is  mixed  with  it.  The  conglomeration  of  the  pus  globules  into  masses,  or 
lines,  as  seen  under  the  microscope,  may  be  taken  as  proof  of  commencing  change 
in  their  structure,  and  so  far  may  be  regarded  as  evidence  that  the  bladder  is  the 
seat  of  the  ail'ectiuu  rather  than  the  kidney. 

§  3.  Ischuria. — This  term  is  employed  to  express  suppression  in 
opposition  to  retention  of  urine:  the  fluid  is  not  secreted  at  all. 
Coming  on  sometimes  after  exposure  to  cold,  it  occasionally  appears 
withoiit  any  very  direct  cause:  rarely  seen  in  perfectly  healthy 
conditions  of  the  organ,  it  is  more  usually  met  with  in  cases  of  low 
inflammation  supervening  on  long  standing  disease.  The  eye  of 
the  experienced  practitioner  will  discover  in  the  aspect  of  his  patient 
those  evidences  of  renal  disease  which  wre  shall  have  to  notice  under 
albuminuria;  but  to  the  patient  and  his  friends  the  existence  of 
such  a  malady  is  unknown.  He  conceives  himself  to  have  been  in 
his  usual  health  when  the  attack  comes  on;  he  cannot  understand 
why  it  is  that  he  passes  no  urine,  as  he  feels  little  or  no  pain,  and 
complains  of  no  suffering.  There  is  nothing  to  mark  the  disorder 
in  its  commencement  besides  the  suppression,  but  soon  the  pulse 
becomes  slow,  the  patient  drowsy,  and  ultimately  completely  coma- 
tose. The  very  same  sequence  occurs  more  slowly  without  complete 
suppression  when  the  clepuratory  action  of  the  kidney  is  much  in- 
terfered with ;  here  they  are  only  more  rapidly  developed.  It  may 
be  the  immediate  result  of  an  attack  of  nephritis;  and  the  common 
occurrence  of  rigor  at  its  commencement  suggests  the  probability 
that,  even  when  the  organ  is  unsound,  some  congestive  or  inflam- 
matory action  is  excited,  which  deprives  the  secreting  structure  that 
remains  of  its  power  of  carrying  on  functions  which,  impaired 
though  they  be,  are  still  necessary  to  life. 

Little  need  be  added  in  regard  to  its  diagnosis.  The  chief  point 
is  to  make  sure  that  the  bladder  is  empty,  and  this  can  only  be 
done  by  a  careful  introduction  of  the  catheter.  No  surgeon  should 
leave  the  hospital  to  enter  upon  general  practice  without  feeling 
confident  that  he  is  competent  properly  to  manipulate  this  delicate 
instrument;  for  even  now  incalculable  mischief  is  frequently  per- 
petrated through  ignorance  or  want  of  skill. 

§  4.  Albuminuria. — Among  the  various  deviations  from  the 
normal  or  healthy  condition  of  the  urine,  this  is  unquestionably 
that  most  frequently  met  with,  and  in  diagnosis  the  most  important, 
whether  we  consider  the  serious  consequences  to  the  patient  which 
directly  spring  from  a  permanent  condition  of  albuminuria,  or  its 
influence  in  modifying  or  giving  rise  to  other  disorders  which  may 
be  indirectly  traced  to  disease  of  the  kidney.  The  name  does  not 
merely  imply  that  the  urine  contains  albumen,  but  is  used  to 
express  a  condition  which  we  know  to  be  associated  with  organic 
change  of  structure  in  the  kidney.     I  have  preferred  employing  it, 


ALBUMINURIA.  367 

because  the  nomenclature" of  diseases  of  the  kidney  has  undergone 
some  changes  of  late,  which  have  rendered  the  meaning  of  "  Bright's 
disease"  somewhat  uncertain;  because,  too^there  seems  no  great 
practical  advantage  in  discriminating  (if  they  can  be  distinguished 
during  life)  between  a  small  granular  kidney  and  a  large,  smooth, 
and  mottled  one;  and,  still  more,  because  it  is  the  presence  of 
albumen  in  the  urine  from  day  to  day,  and  the  partial  absence  of 
other  constituents,  which  produce  the  baneful  consequences  on  the 
patient's  health.  Albuminous  urine  during  life  is  to  us  much  more 
important  than  the  changes  of  structure  revealed  by  dissection: 
the  presence  of  albumen  is  the  fact  which  can  be  readily  appre- 
ciated in  diagnosis,  and  which,  coupled  with  diminished  specific 
gravity,  implies  the  deficiency  of  other  elements — a  circumstance 
not  less  important,  but  not  so  easily  ascertained  by  analysis:  and 
the  name  albuminuria  will  equally  express  the  effect  of  destruction 
of  tissue  by  the  development  of  cysts,  of  the  absorption  caused  by 
dilated  ureters  and  tubes  from  pressure  or  obstruction,  and  the 
more  common  condition  found  in  degeneration,  by  whatever  name 
that  may  be  designated. 

The  commencement  of  the  disease  is  very  rarely  traceable. 
Some  have  thought  they  might  venture  to  go  back  to  an  attack  of 
scarlatina ;  occasionally  we  may  have  a  really  truthful  history  of 
an  attack  of  nephralgia,  which  post-mortem  appearances  enable  us 
to  associate  with  the  subsequent  changes ;  but  these  are  the  curiosi- 
ties of  diagnosis,  and  their  practical  value  is  not  great. 

The  patient  gradually  loses  strength,  becomes  pale,  finds  himself 
liable  to  catch  cold,  or  suffers  from  headache,  or  from  diarrhoea:  in 
fact  the  symptoms  presented  are  exceedingly  ill-defined,  and  it  may 
be  not  until  anasarca  make  its  appearance  that  he  supposes  himself 
seriously  ill.  When  questioned,  he  will  generally  admit  that  he 
has  suffered  from  pain  in  the  loins  of  a  dull,  aching  kind:  but  how 
many  suffer  in  the  same  way,  from  weakness  only,  who  never  have 
albuminous  urine.  The  circumstances  in  the  aspect  of  the  patient 
which  prepare  us  for  the  discovery  of  albumen  in  the  urine  are  a 
waxy  or  an  extremely  pallid  face,  with  pearly  eyes,  and  puffiness 
round  the  eyelids,  or  oedema  of  the  ankles,  which  the  attendant 
may  notice  before  the  patient  becomes  conscious  of  it.  Such  indi- 
cations are  the  more  valuable,  inasmuch  as  the  albumen  may  for  a 
time,  in  the  progress  of  the  case,  be  reduced  to  a  mere  trace ;  in 
fact,  it  occasionally  disappears  altogether,  and  repeated  analyses 
may  be  needed  to  make  out  the  true  nature  of  the  case.  But  they 
are  only  to  be  regarded  as  hints  of  what  may  probably  be  dis- 
covered: they  result  from  the  cachexia  of  the  disease,  and  may  be 
seen  in  other  cachectic  states,  of  which  anemia  is  a  prominent 
characteristic. 

When  dropsy  is  fairly  established,  it  then  becomes  of  importance, 
in  regard  to  treatment,  to  have  clear  notions  of  its  cause;  and  as 
has  been  already  pointed  out,  the  first  question  is  whether,  if  there 


308       DISEASES  OF  THE  URINARY  ORGANS. 

be  coincident  ascites,  the  effusion  occurred  first  in  the  abdomen  or 
in  the  areolar  tissue;  then,  in  following  the  order  we  have  adopted, 
the  condition  of  the  Jieart  must  be  carefully  examined;  next  we 
inquire  whether  there  be  any  circumstances  which  point  to  dise 
of  the  liver;  and  lastly  we  examine  the  urine.  I>ut  the  existence 
of  one  form  of  disease  does  not  exclude  the  possibility  of  another 
being  conjoined  with  it;  on  the  contrary,  we  know  that  there  is  a 
constant  alliance  between  disease  of  the  heart  and  disease  of  the 
kidney. 

a.  In  all  cases  an  abundance  of  pale,  limpid  urine,  of  low  specific 
gravity,  -which  yields  a  distinct  precipitate  of  albumen,  affords  cer- 
tain evidence  of  serious  disease  of  the  kidney. 

b.  A  very  abundant  precipitate  of  albumen,  whatever  be  the 
condition  of  the  urine,  can  only  be  caused  by  disease  of  the  kidney, 
whether  in  the  form  of  congestion  or  simple  inflammation,  or  of 
scarlatinal  nephritis,  or  of  degeneration  at  a  particular  stage,  or  of 
a  special  form. 

c.  If  the  amount  of  albumen  be  small,  the  evidence  of  its  presence 
doubtful,  and  the  secretion  scanty,  the  inference  is  less  certain  when 
disease  of  the  heart  exists,  because  passive  congestion  of  various 
organs  is  one  of  its  usual  concomitants.  AVhen,  therefore,  there  is 
evidence  of  valvular  lesion  traceable  to  rheumatic  attacks,  urine, 
which  is  scanty  and  loaded,  may  continue  for  a  time  to  contain  a 
trace  of  albumen,  while  no  disease  of  the  kidney  exists:  -when,  on 
the  other  hand,  the  heart-disease  is  of  the  form  of  hypertrophy,  or 
dilatation,  the  continuance  of  a  trace  of  albumen  is  a  more  suspi- 
cious sign,  because  it  is  not  improbable  that  the  changes  in  its 
muscular  structure,  as  they  are  not  caused  by  valvular  lesion,  may 
be  the  effects  of  renal  disease.  In  either  case  the  diagnosis  can 
only  be  considered  certain  when,  with  an  increase  of  the  secretion, 
the  albumen  persists,  and  the  specific  gravity  falls.  Somewhat 
similar  relations  have  been  observed  when,  in  cases  of  dropsy 
dependent  on  other  causes,  any  special  circumstance  gives  rise  to 
congestion  of  the  kidney:  such,  for  example,  as  anasarca  accom- 
panying ascites  or  ovarian  dropsy,  when  pressure  opposes  the  return 
of  the  blood  through  the  renal  veins ;  an  exactly  analogous  relation 
is  said  to  exist  very  frequently  in  the  dropsy  of  pregnancy. 

d.  "When  dropsy  is  not  present  there  are  no  doubt  many  circum- 
stances which  may  give  rise  to  the  casual  occurrence  of  a  trace  of 
albumen ;  and  when  this  change  is  not  constant,  and  the  specific 
gravity  is  normal,  great  hope  may  be  entertained  that  the  condition 
of  disease  is  only  transient,  and  not  altogether  beyond  the  reach  of 
art.  In  investigating  these  cases  the  microscope  may  be  of  much 
service  in  showing  either  the  presence  of  a  few  blood-globules,  or 
of  pus,  or  what  are  called  exudation-corpuscles,  or  mucus-globules 
in  such  numbers  as  to  resemble  pus  rather  than  mucus,  all  of  which 
arc  found  in  simple  congestion  of  the  kidney;  or  it  may  discover 
fibrinous  casts  of  the  tubuli,  which  can  only  be  present  in  very 


ALBUMINURIA.  3G9 

active  congestion,  or  in  permanent  disorganization.  These  casts 
present  either  a  homogeneous  appearance,  smooth  and  transparent, 
or  they  are  filled  up  with  granular  matter,  and  sometimes  they 
contain  blood-globules  or  particles  of  oil.  The  smooth  or  waxy 
casts,  as  they  are  called,  serve  to  indicate  the  most  advanced  con- 
dition of  disease,  and  those  containing  blood-globules  generally 
result  from  congestion ;  but  their  appearance  must  not  be  made  too 
absolutely  a  guide  to  diagnosis. 

e.  When  the  urine  is  tinged  with  blood,  the  indications  are  some- 
what similar  to  those  derived  from  the  presence  of  albumen,  and 
what  is  true  of  the  one  is  in  great  part  true  of  the  other,  with  this 
difference,  that  blood  may  come  from  any  part  whatever  of  the 
urinary  organs  and  passages.  The  first  question  when  blood  is 
present  is,  whether  more  albumen  can  be  precipitated  than  is 
accounted  for  by  the  admixture  of  blood  if  it  had  been  added  after 
the  urine  was  voided.  This  is  a  point  which  experience  only  can 
determine,  and  for  which  no  rules  can  be  laid  down.  When  we 
conceive  the  amount  of  albumen  to  be  greater  than  would  be  con- 
tained in  urine  coloured  by  blood  to  the  same  extent,  it  must  be 
regarded  just  as  if  the  blood  were  not  present,  for  we  know  that  the 
excess  of  albumen  must  be  secreted  by  the  kidney:  when  the 
amount  of  albumen  is  small,  the  next  question  is  as  to  the  source 
of  the  hemorrhage;  and  probably  the  only  reliable  evidence  of  its 
coming  from  the  kidney  is  when  the  microscope  discovers  tubular 
casts.  The  existence  of  small  clots,  visible  to  the  naked  eye-,  proves 
that  the  hemorrhage  has  occurred  in  some  part  of  the  canal  from 
its  commencement  in  the  pelvis  of  the  kidney  to  its  termination  at 
the  end  of  the  urethra;  and  then  there  are  generally  local  symptoms 
to  guide  us  in  determining  at  what  point  it  took  place.  Sometimes 
it  is  distinctly  passed  before  the  urine  begins  to  flow,  and  it  probably 
issues  from  the  urethra;  sometimes  it  only  escapes  with  the  last 
drops  of  urine,  when  its  source  is  generally  the  bladder.  In  females, 
blood  flowing  from  the  uterus  may  be  mixed  with  the  urine  as  it  is 
voided:  hoematuria  is  also  one  of  the  forms  of  hemorrhage  which 
occurs  without  any  special  lesion,  depending  simply  on  a  deficiency 
of  plastic  material  in  the  blood  itself.  It  is  only  when  the  blood 
retains  somewhat  of  its  natural  colour,  and  the  urine  is  red  or 
pinkish,  that  doubts  regarding  the  source  of  the  hemorrhage  can  be 
entertained:  when  dark-coloured  or  smoky,  the  blood  almost  cer- 
tainly comes  from  the  kidney. 

We  do  not  class  the  albuminous  urine  which  accompanies  the  presence  of  pus- 
globules  under  the  head  of  albuminuria,  because  we  presume  that,  in  the  exami- 
nation of  the  deposit,  this  fact  has  been  observed,  and  it  serves  to  characterize  dis- 
tinct conditions  of  the  kidneys  or  urinary  passages.  It  must,  however,  be  remem- 
bered that  one  of  the  features  by  which  we  are  enabled  to  distinguish  pus  coming 
from  the  substance  of  the  kidney,  is  that  the  urine  contains  an  excess  of  albumen 
beyond  that  which  is  accounted  for  by  the  admixture  of  liquor  puris.  In  this  re- 
spect it  is  very  analogous  to  hasmaturia,  and  the  question  of  whether  the  kidney 
be  directlv  involved  is  to  be  determined  simply  by  ascertaining  whether  it  do  or 

24 


:]T0  DISEASES    OF   THE    URINARY    ORGANS. 

do  not  secrete  albumen:  the  great  difference  between  the  two  is  that  the  blood  is 
.„„,,.  |  of  chronic  disease  us  an  accidental  admixture,  while  pus  jn- 

,1',,..,.  ,'ml  condition,  and  the  albumen  is  only  present  because  the  kidney  is 

altered  in  function  and  structure  by  the  Buppuration. 

In  both  cases  it  is  possible  that  the  abnormal  ingredients  may  have  separate 

sour,  albumen  coining  from  the  kidney,  and  the  blood  or  the  pus  from  the 

[er  or  urinary  passages.     Against  such  coincidences  it  is  almost  impossible 

iard,  and  it  would  lie  vain  to  attempt  to  lay  down  rules  for  diagnosis:  but  they 

areiu  practice  not  of  very  frequent  occurrence;  the  accidental  hemorrhage  would 

not  very  greatly  modify  the  treatment  of  the  prominent  disease  of  the  kidney,  and 

•nee  of  pus  would  lead  to  the  adoption  of  similar  measures,  whether  its 

source  were  the  kidney  or  not,  when  it  was  found  in  a  patient  with  albuminuria. 

The  absolute  diagnosis  is  therefore  not  very  essential ;  and  probably  some  other 

symptom  would  suggest  the  bladder  as  the  seat  of  suppuration  or  hemorrhage 

when  they  did  not  proceed  from  the  kidney. 

In  its  results  to  the  economy  at  large,  permanent  disorganization  of  these  glands 
is  a  disease  of  the  greatest  importance:  the  constant  drain  of  albumen,  which  at 
times  passes  off  in  enormous  quantity,  establishes  a  state  of  anaemia  which  is  more 
or  less  the  cause  of  many  of  the  secondary  ailments  which  spring  from  it:  and,  at 
the  same  time,  the  retention  of  effete  matters,  which  are  usually  evacuated  by  this 
channel,  seems  to  produce  a  sort  of  blood-poisoning  which  increases  the  anajmia, 
and  is  the  more  immediate  exciting  cause  of  the  diarrhoea,  and  the  plastic  exuda- 
tions which  so  often  appear  during  its  progress. 

§  5.  Diuresis. — As  a  temporary  effect  of  direct  stimulation  of 
the  kidney,  an  excessive  secretion  of  urine  is  sufficiently  common ; 
its  persistence  is  very  unusual,  except  as  a  sign  of  diabetes.  In 
diagnosis,  as  in  pathology,  the  indications  are  wholly  negative :  it 
has  to  be  ascertained  that  there  is  no  sugar  and  no  albumen:  the 
urine  is  of  low  specific  gravity,  and  there  cannot  be  any  very 
unusual  metamorphosis  of  tissue;  but  yet,  when  the  quantity  of 
urine  is  great,  no  doubt  more  solid  matter  passes  out  of  the  body 
than  in  health,  and  hence  there  is  commonly  some  emaciation.  At 
present  it  does  not  appear  that  any  logical  view  of  its  cause  has 
been  suggested. 

The  secretion  of  pale,  limpid  urine,  as  an  effect  of  the  hysteric 
pa#oxysm,  has  been  already  mentioned;  but  sometimes  a  spurious 
diuresis  is  kept  up  for  a  long  time  in  hysterical  persons  by  what 
might  be  termed  a  dypsomania,  in  which  enormous  quantities  of 
fluid  are  drunk  during  the  day,  and  of  course  find  an  outlet  by  the 
kidney. 

§  6.  Cystitis. — Inflammation  of  the  bladder  is  a  frequent  source 
of  pus  in  the  urine:  the  urgency  to  frequent  evacuation  which 
marks  suppuration  in  the  kidney  is  not  so  great  in  cystitis,  or  it  is 
of  another  kind.  The  history  very  often  dates  from  some  retention 
of  urine  in  the  first  instance,  as,  for  example,  an  unavoidable  delay 
in  emptying  the  bladder,  followed  by  over  distention  and  subsequent 
spasm,  with  fruitless  efforts  at  micturition;  perhaps  the  presence  of 
stricture  in  males,  or  in  females  the  pressure  of  an  enlarged  uterus 
renders  it  impossible  thoroughly  to  empty  it.  It  is  immaterial 
whether  the  first  distention  be  the  cause  of  the  inflammatory  action 
which  ensues,  or  whether  the  retention  of  a  small  portion  of  urine 


DIABETES.  371 

on  each  occasion  lead  to  its  decomposition,  and  this  fetid  urine 
acting  as  a  ferment  on  what  is  subsequently  secreted,  the  whole 
contents  of  the  bladder  become  ammoniacal,  and  so  irritate  the 
mucous  membrane,  and  give  rise  to  purulent  secretion.  The  latter 
is  evidently  the  mode  in  which  cystitis  is  developed  in  paraplegia, 
accompanied  by  paralysis  of  the  bladder,  because,  by  carefully 
washing  it  out  daily  with  warm  water  the  inflammation  may  be 
averted. 

In  other  cases  cystitis  occurs  as  the  consequence  of  stone  in  the 
bladder,  the  symptoms  of  which  form  no  part  of  medical  diagnosis: 
it  is  only  worthy  of  remark  that  the  irritability  of  the  bladder  con- 
nected with  calculus,  while  causing  its  frequent  evacuation,  is 
specially  accompanied  by  pain  over  the  arch  of  the  pubis,  at  the 
glans  penis,  or  in  the  perimeum ;  and  that  for  a  long  time  the  urine 
continues  to  be  clear  and  transparent  after  the  irritation  ha3  been 
excited,  not  thick  and  opaque  as  when  mixed  with  pus,  because  the 
purulent  secretion  is  only  a  later  event  in  the  progress  of  the  case. 
In  inquiring  into  the  .origin  of  symptoms,  a  distinction  must  be 
made  between  the  difficulty  in  passing  the  urine,  when  it  is  voided 
in  a  small  stream  in  stricture,  and  the  sudden  stoppage  of  a  full 
stream  which  occurs  in  cases  of  stone. 

Sometimes  cystitis  comes  on  as  a  catarrh  of  the  bladder  propa- 
gated from  the  urethra,  in  cases  of  gonorrhoea:  simple  idiopathic 
catarrh  is  necessarily  very  rare. 

The  principal  source  of  information  is  the  condition  of  the  urine 
itself:  when  pus  is  derived  from  the  kidney,  as  a  general  rule  the 
urine  is  acid  and  the  pus  falls  as  a  sediment  to  the  bottom;  when 
derived  from  the  bladder,  the  urine  is  alkaline,  and  the  pus  more 
or  less  altered  in  character,  becoming  ropy  and  resembling  mucus. 
Casual  circumstances  and  the  effect  of  treatment  may  alter  these 
facts  for  a  time,  but,  when  observed  in  the  first  instance,  or  remarked 
as  the  usual  condition,  the  evidence  they  afford,  combined  with  the 
history  of  the  case,  are  quite  characteristic  of  the  true  nature  of 
the  disease  in  each  of  its  forms. 

§  7.  Diabetes.  The  chemical  test  for  the  presence  of  sugar  is  a 
»very  certain  one  if  applied  with  sufficient  care:  but  the  whole  cir- 
cumstances connected  with  confirmed  diabetes  are  so  distinct  that 
the  diagnosis  scarcely  requires  this  corroboration.  Unfortunately 
there  are  few  symptoms  which  can  lead  to  its  early  detection:  the 
amount  of  urine  passed  in  the  twenty-four  hours  is  so  little  regarded 
by  most  persons  that  they  seldom  think  of  adverting  to  it  till  it  be 
in  very  great  excess:  it  is  generally  the  existence  of  weakness  and 
emaciation  which  excites  the  patient's  attention;  sometimes  the  cir- 
cumstance is  observed  that  where  the  urine  fails  it  leaves  a  white 
crust  when  it  dries ;  sometimes  the  unusual  appetite  and  craving 
for  drinks  leads  him  to  suspect  that  something  is  wrong. 

To  the  eye  of  the  practitioner  the  emaciation  of  diabetes  is  very 


372  DISEASES   OF   TIIE    URINARY    ORGANS. 

different  from  that  of  other  diseases;  it  is  not  marked  by  any  un- 
heal; hv  appearances  such  as  characterize  the  various  cachectic  states: 
its  combination  with  hunger  may  lead  to  the  suspicion  of  the  exist- 
ence of  intestinal  worms,  but  in  following  the  scheme  for  the  ex-- 
animation  of  the  patient  laid  down  in  the  early  part  of  this  work, 
the  very  next  inquiries  lead  us  at  once  to  the  true  explanation. 
Along  with  the  emaciation  and  craving  appetite  thirst  is  excessive, 
the  urine  is  secreted  in  large  quantity,  the  bowels  are  costive,  and 
the  fieces  dry  and  solid:  under  no  other  condition  of  disease  is  the 
same  train  of  symptoms  ever  remarked. 

§  8.  Disordered  Function. — Under  the  name  of  functional  dis- 
turbance must  be  included  variations  in  the  proportion  of  water  and 
other  normal  constituents  which,  as  they  are  elaborated  elsewhere, 
may  pass  out  of  the  body  through  the  kidneys  without  implying 
specific  disease  of  any  portion  of  the  urinary  apparatus.  They 
cannot  be  easily  classed  according  to  the  disease  with  which  they 
are  commonly  associated ;  but  assuming  that  the  history  of  the  case 
and  the  examination  of  other  organs  has  already  led  to  an  opinion 
bein^  formed  on  its  nature,  we  have  to  inquire  what  additional  light 
may  be  derived  from  an  examination  of  the  urine. 

Excess  of  water,  while  it  constitutes  the  whole  disease  in  what  is 
called  diabetes  insipidus,  and  is  present  very  frequently  in  albumi- 
nuria, and  constantly  in  diabetes,  may  be  casually  observed  after 
certain  ingesta  which  stimulate  the  kidneys,  and  after  an  hysteric 
paroxysm:  in  such  cases  it  is  really  of  no  importance. 

Deficiency  of  water  is  most  remarkable  in  fevers,  and  in  cases  in 
which  the  perspiration  is  excessive:  it  is  also  observed  when  diar- 
rhoea exists,  and  sometimes  as  an  effect  of  dyspepsia,  the  urine  be- 
coming acid,  scanty,  and  loaded,  irritating  the  bladder  and  urinary 
passages.  The  secretion  is  also  scanty  when  the  renal  circulation 
is  interfered  with  by  abdominal  distention  or  disease  of  the  hearty 
though  very  frequently  in  cases  of  the  latter  class  there  is  more 
than  mere  functional  disturbance, — congestion,  if  not  actual  disease 
be^un.  In  dropsy  depending  upon  disease  of  the  kidney,  the  secre- 
tion is  always  diminished  while  anasarca  is  on  the  increase,  partly 
as  its  cause,  but  partly  too  as  its  effect.  # 

"When  the  proportion  of  water  falls  much,  below  the  healthy 
standard,  those  salts  which  are  more  soluble  in  warm  than  cold 
water,  if  present  in  their  usual  amount,  ought  to  be  precipitated, 
forming  a  sediment:  but  here  another  law  comes  into  play,  because 
their  chemical  constitution  varies  with  the  amount  of  what,  for  con- 
venience, we  may  term  free  acid  or  free  alkali.  If  free  acid  be 
present,  the  lithates  exhibit  that  form  in  which  they  are  less  solu- 
ble in  cold  than  warm  urine,  and  they  are  precipitated;  if  free  al- 
kali be  present,  their  condition  is  changed,  and  they  are  held  in 
solution  by  a  much  smaller  quantity  of  water.  The  deposition  of 
jmosphatic  or  earthy  salts  is  not  so  dependent  on  the  proportion  of 


FUNCTIONAL    DISORDERS.  373 

water,  for  they  are  very  easily  dissolved  by  free  acid,  and  are  very 
insoluble  when  free  alkali  is  present. 

This  explains  to  us  why  in  acute  rheumatism,  when  acid  abounds, 
and  there  are  copious  sour-smelling  perspirations,  the  urine  is  always 
loaded  with  lithates;  whereas  in  typhus,  when  the  powers  of  life 
are  low,  and  free  alkali  is  liable  to  be  secreted  by  the  kidney,  the 
urine  may  be  very  scanty  and  very  deep-coloured,  and  yet  there  is 
no  deposit  till  some  acid  be  added,  when  the  whole  becomes  turbid. 
Such  urine  oftentimes  appears  slightly  acid  to  test-paper,  and  it 
would  appear  that  the  lithate  is  secreted  in  a  soluble  form  with  ex- 
cess of  alkali,  and  that  the  affinity  of  the  acid  is  too  weak  subse- 
quently to  convert  it  into  the  insoluble  form.  The  fact  is  certain, 
the  explanation  perhaps  unsatisfactory ;  but  it  is  the  only  one  which 
our  chemical  knowledge  of  these  salts  at  present  gives. 

When  acid  is  formed  in  excess  in  the  stomach  in  dyspepsia,  and 
afterwards  passes  off  by  the  kidney,  it  tends  to  check  the  flow  of 
urine,  causing' a  deficiency  of  water,  and  at  the  same  time  it  deter- 
mines the  formation  of  the  less  soluble  lithates,  which  the  small 
quantity  of  water  present  cannot  hold  in  solution  when  cold.  To 
speak  therefore  of  an  excess  of  lithates  is  a  fallacy,  because  their 
deposition  may  depend  merely  on  the  proportion  of  water,  or  may 
be  wholly  prevented  by  deficiency  of  acid.  When  lithic  acid  is 
really  in  excess,  it  is  more  likely  to  occur  in  a  crystalline  form,  un- 
combined  with  any  base;  and  to  this  the  name  of  the  "lithic  acid 
diathesis"  more  properly  belongs  than  to  that  in  which  the  deposit 
is  amorphous. 

To  speak  of  an  excess  of  earthy  phosphates  is  a  more  complete 
fallacy  than  that  just  alluded  to.  They  are  so  very  soluble  when 
free  acid  is  present,  so  insoluble  when  free  alkali  is  present,  that 
such  a  deposit  indicates  nothing  more  than  the  fact  of  the  urine 
being  alkaline.  It  is  true  that,  as  happens  with  the  lithates  in  ty- 
phus, the  urine  may  have  a  slightly  acid  reaction  to  test-paper,  and 
yet  earthy  phosphates  may  be  deposited ;  and  the  only  explanation 
that  can  be  given  is  that  they  have  been  secreted  in  an  alkaline 
condition,  but  the  acid  present  is  too  weak  to  alter  their  chemical 
relations;  for  a  single  drop  of  stronger  acid  at  once  dissolves  the 
deposit.  Valuable  information  might  no  doubt  be  obtained  from  a 
knowledge  whether  the  phosphoric  acid  be  really  in  excess;  but 
this  can  only  be  ascertained  by  a  quantitative  analysis,  which  re- 
quires much  chemical  skill  and  much  expenditure  of  time. 

A  deposit  of  earthy  phosphates  then  only  shows  that  alkali  of 
some  sort  is  in  excess.  Of  this  there  are  three  principal  causes: 
the  decomposition  of  urea  yielding  free  ammonia;  the  ingestion  of 
alkalies  or  decomposable  alkaline  salts;  and  the  secretion  of  excess 
of  ammonia  by  the  kidney.  The  first  of  these,  when  the  urine  is 
fetid,  is  very  generally  associated  with  cystitis,  and  is  also  developed 
in  a  very  short  space  of  time  in  urine  which  was  alkaline  on  emis- 
sion ;  the.  second  is  only  a  casual  occurrence,  which  has  no  patholo- 


o74       DISEASES  OF  THE  URINARY  ORGANS. 

gical  value,  and  is  only  to  be  borne  in  mind  as  one  of  the  possible 
causes;  the  third  is  that  to  which  the  name  of  the  phosphatic  dia- 
thesis has  been  given.  It  is  evidently  connected  with  states  of  de- 
bility, especially  with  exhaustion  of  nervous  energy:  we  do  not  ex- 
pect to  find  it  always  present,  because  of  the  constant  daily  varia- 
tions in  the  acidity  of  the  urine,  but  its  recurrence  at  certain  periods 
may  aid  us  in  ascertaining  its  specific  causes.  It  should  be  remem- 
bered, too,  that  the  amount  of  acid  in  the  stomach  at  any  given 
period  is  generally  in  an  inverse  proportion  to  that  in  the  urine, 
and  I  have  seen  this  most  strikingly  exemplified  in  cases  of  sarcina 
ventriculi  when  the  fermentation  going  on  in  the  stomach  produced 
the  greatest  possible  degree  of  alkalescence.  Closely  related  to 
this  change  is  one  in  which,  without  fetor  or  absolute  decomposition, 
the  urea  is  converted  into  the  carbonate  of  ammonia,  a  change  which 
is  hastened  by  boiling,  and  gives  rise  to  effervescence  on  the  addi- 
tion of  acid. 

In  general  terms,  speaking  of  acidity  and  alkalescence  of  urine,  we  find  them 
associated  with  very  opposite  conditions  of  health,  modified  by  the  actual  state  of 
the  stomach  at  the  period  when  the  fluid  is  secreted.  A  man  of  full  habit,  who 
indulges  in  the  pleasures  of  the  table,  and  is  not  disposed  to  overtax  his  mental 
powers  or  his  nervous  system,  is  very  likely  to  exhibit  in  his  urine  copious  depo- 
sits of  the  lithate  of  ammonia,  especially  at  those  times  when  he  has  been  suffer- 
ing from  acidity  of  stomach,  and  that  acid  has  begun  to  pass  off  by  the  kidney. 
"Whereas  a  man  of  spare  habit  and  nervous  temperament,  during  the  period  of  ex- 
haustion following  any  excitement  either  of  brain  or  nerve,  is  very  liable  to  phos- 
phatic deposits,  especially  while  the  acid  is  still  in  the  stomach,  and  before  it  has 
begun  to  pass  off  by  the  kidney.  On  the  other  hand,  the  urine  of  one  whose  di- 
gestive organs  are  in  an  enfeebled  state  will  contain  the  one  deposit  or  the  other, 
according  to  the  period  after  food  at  which  it  is  examined. 

I  think  we  may  notice,  with  regard  to  the  lithates  deposited  in  such  circum- 
stances, that  those  simply  dependent  on  gastric  derangement  are  of  a  paler  colour 
than  those  which  are  produced  by  any  excess.  To  some  it  has  appeared  that  the 
pink  colour  was  caused  by  chemical  alteration  of  the  same  colouriug  matter  which 
is  secreted  by  the  liver,  and  the  staining  of  the  utensil  has  been  taken  as  evidence 
of  biliary  derangement:  the  investigation  of  this  point  is  not  complete,  but  it  may 
be  usefully  remembered  in  practice. 

Excess  of  urea  is  also  one  of  the  functional  disturbances  of  the 
secretion.  It  is  to  be  regarded  as  a  proof  of  excessive  metamor- 
phosis of  the  nitrogenized  elements,  whether  in  consequence  of  a 
too  abundant  supply,  or  of  unusual  waste  of  tissue,  as  it  follows  on 
the  use  of  nitrogenized  food  in  excess,  or  is  increased  by  disease. 
There  is  apparently  no  specific  cause  to  which  it  can  be  attributed; 
we  must  be  content  at  present  to  employ  such  general  expressions 
as  disorder  of  stomach  and  depressing  influences,  while  observing 
the  fact  of  general  emaciation,  sense  of  lassitude,  and  depression  of 
mind  which  accompany  its  existence. 

It  is  often  associated  with  a  deposit  of  oxalic  acid,  in  the  form  of 
oxalate  of  lime.  Probably  too  great  stress  has  been  laid  on  the 
presence  of  this  salt,  which  has  been  often  regarded  as  the  first  step 
in  changes  of  which  it  is  perhaps  really  the  result;  and  this  con- 
clusion is  the  more  probable  from  the  very  many  and  very  varied 


FUNCTIONAL   DISORDERS.  375 

circumstances  in  -which  it  is  found.  It  coexists  with  alkaline  urine 
and  deposits  of  phosphates,  with  acid  urine  and  amorphous  lithates, 
with  crystals  of  uric  acid,  as  well  as  with  excess  of  urea:  but  we 
may  always  trace  indications  of  weakness  and  depression,  whatever 
other  special  characters  the  case  exhibits.  We  need  not  .stop  to 
inquire  whether  it  be  formed  by  a  reconversion  of  some  of  the 
normal  ingredients,  or  by  imperfect  oxidation  of  carbon  in  the 
lungs,  or  whether  it  be  formed  at  once  in  the  process  of  assimilation, 
and  carried  into  the  urine  as  it  is  when  food  containing  oxalic  acid 
is  taken  into  the  stomach. 

Many  other  functional  disorders  might  be  enumerated,  but  they  are  chiefly  mat- 
ters of  curiosity;  such,  for  example,  as  the  presence  of  fibrine  in  chylous  urine,  of 
oily  matter,  of  kiestine  in  the  urine  of  pregnancy,  of  a  milky  albuminous  matter 
in  malacosteon,  &c.  These  cases  are  so  rare  that  the  student  must  be  referred  to 
works  on  diseases  of  the  kidney  for  further  information  regarding  them.  It  may 
be  added  that  haematuria  is  to  be  regarded*  as  a  functional  disorder  when  it  de- 
pends only  on  some  change  in  the  condition  of  the  blood,  such  as  is  manifested  in 
other  parts  of  the  body  by  spots  of  purpura,  or  by  uncontrollable  hemorrhage. 

The  entire  dependence  of  functional  disorder  on  causes  altogether  beyond  the 
kidney  itself,  is  not  less  remarkable  than  the  extensive  associations  of  its  diseases 
with  those  occurring  in  other  organs.  Among  fevers  we  find  scarlatina  giving 
rise  to  a  form  of  nephritis  with  albuminuria:  certain  forms  of  chronic  rheumatism 
and  gout  seem  to  be  more  or  less  depe'ndent  on  degeneration  of  the  kidney;  and 
the  connexion  existing  between  gout  and  uric  acid  brings  that  disease  into  close 
relation  with  the  crystalline  deposit  in  the  urine. 

Dropsy  is  connected  in  two  ways  with  disease  of  the  kidney;  as  it  is  induced  by 
deficient  secretion  of  water,  which  thus  necessarily  accumulates  in  the  system,  or 
by  changes  slowly  developed  in  the  blood  rendering  its  watery  portion  more  liable 
to  transude  through  the  vessels  into  surrounding  tissues.  The  same  condition 
gives  rise  at  times  to  hemorrhages,  especially  epistaxis,  and  is  always  marked  by 
the  waxy  or  pallid  hue  of  anaemia.  Tubercular  phthisis  often  forms  the  conclusion 
of  a  case  of  diabetes;  chorea  and  delirium  tremens  are  each  said  to  cause  impor- 
tant changes  in  the  relative  amounts  of  certain  of  the  constituents  of  the  urine. 

Head  affections  are  in  a  most  especial  manner  associated  with  disease  of  the 
kidney;  convulsions  and  coma  are  often  the  precursors  of  its  fatal  termination, 
whether  caused  by  urasmic  poisoning,  or  by  serous  effusion  in  the  ventricles.  In 
a  large  proportion  of  cases  of  apoplexy,  granular  degeneration  is  found,  but  the 
connexion  of  the  two  is  probably  to  be  traced  to  disease  of  the  heart,  which  is  so 
common  in  albuminuria.  Occasionally  this  exists  as  simple  hypertrophy;  at  other 
times  there  is  atheromatous  disease  of  the  valves,  and  perhaps  of  the  arteries:  the 
former  apparently  produced  by  disturbed  circulation,  the  latter  probably  only  ano- 
ther expression  of  that  faulty  nutrition  which  also  affects  the  kidney. 

Plastic  exudations  on  serous  surfaces  are  to  be  met  with  in  the  pericardium,  in 
the  pleura,  and  in  the  peritoneum  more  commonly  than  in  other  circumstances; 
and  both  bronchitis  and  laryngitis  are  more  severe  in  consequence  of  the  tendency 
to  oedema  to  which  it  gives  rise.  The  liver  not  uncommonly  presents  evidence  of 
coincident  disease,  which  it  is  not  difficult  to  explain  when  we  recognise  habits  of 
intemperance  as  the  constant  source  of  mischief  to  both  organs. 


376 


CHAPTER  XXXII. 

DISEASES    OP   THE    OVARIES. 

General  Considerations  —  Obscure  Origin  —  Associations.  —  §  1 , 
Ovarian  Drops)/ — Resemblance  to  Ascites — Distinguishing  Cha- 
racters— §  2,  Tumours — known  by  their  Pelvic  Attachments — 
distinguished  from  Pregnancy. 

In  adverting  to  classes  of  disease  peculiar  to  the  female  sex,  it  must  be  remem- 
bered that  they  are  often  mixed  up  with  hysteria,  and  while  that  undefined  malady 
may  give  rise  to  symptoms  in  any  organ  of  the  body,  and  may  simulate  any  form 
of  disease,  the  practitioner  must  be  on  his  guard  against  assuming  symptoms  to 
be  merely  hysterical  when  they  depend  on  some  obscure  cause  which  he  has  been 
unable  to  trace.  The  early  changes  in  the  ovaries,  as  they  cannot  be  recognised, 
must  therefore  be  borne  in  mind,  as  affording  a  possible  explanation  of  symptoms 
otherwise  unintelligible:  but  this  is  very  different  from  the  views  which  we  cannot 
but  regret  to  see  advocated  by  any  claiming  for  themselves  a  respectable  position 
in  the  profession,  who  would  refer  to  some  undefined  local  changes  all  the  anoma- 
lous characters  which  hysteria  so  constantly  presents.  If  medicine  is  to  be  ranked 
as  a  science,  we  cannot  ignore  the  clear  and  accurate  teachings  of  pathological 
anatomy;  we  may  not  assign  to  any  disease  a  cause  which  post  mortem  examina- 
tion proves  to  have  no  existence;  we  may  not  assume  ovaritis,  as  it  has  been 
called,  to  be  a  common  condition  in  the  living,  when  we  know  that  it  is  seldom 
met  with  in  the  dead  body.  Pathological  anatomy  does  not  teach  us  what  hys- 
teria is,  but  it  teaches  us  in  unmistakeable  language  what  it  is  not,  and  if  we  learn 
the  lesson  it  conveys,  no  truth  will  come  home  with  more  force  of  demonstration 
than  this,  that  neither  ovarian  changes  nor  ulcers  of  the  os  uteri  have  any  thing  to 
do  with  its  occurrence,  except  as  they  figure  in  the  opinion  of  the  practitioner,  or 
engross  the  thoughts  of  the  patient:  more  than  this, — it  also  teaches  that  disease 
of  the  ovaries,  though  not  uncommon,  is  not  of  such  a  kind  as  can  be  traced  to 
"inflammation"  in  any  of  the  multifarious  forms  assigned  to  it.  All  that  can  be 
said  of  ovaritis  is,  that  were  it  present  its  symptoms  would  be  undistinguishable 
from  local  peritonitis  confined  to  the  region  of  the  ovary. 

• 

The  early  history  of  ovarian  growths  is  quite  unknown  to  us.    The 

first  symptom  is  generally  the  patient's  consciousness  of  enlargement 
of  the  abdomen:  as  an  indication  of  disease  this  is  classed  among 
"  alterations  of  size;"  and  it  is  worthy  of  observation  that,  in  exter- 
nal form,  the  abdomen  is  liable  to  be  unequally  prominent  on  one 
side.  The  tumour  may  possibly  be  recognised  by  the  practitioner  be- 
fore its  existence  is  known  to  the  patient  herself — as,  for  example, 
in  pressing  the  abdomen  during  fever,  with  bowel  ailment.  More 
rarely  the  growth  is  found  out  in  searching  for  the  causes  of  con- 
stipation; but  such  a  condition  is  so  common  among  females  in  this 
country  that  it  can  scarcely  lead  to  the  discovery  of  the  disease. 
Among  early  symptoms,  pains  in  the  groins,  and  a  sensation  of 
weight  and  bearing  down  in  the  pelvic  viscera  are  mentioned,  and 
may  be  of  service  in  leading  to  more  careful  examination,  but  they 
are  not  in  any  way  characteristic.     When  enlargement  has  actually 


DISEASES    OF    THE    OVARIES.  377 

taken  place,  it  is  not  unimportant  to  notice  in  how  many  instances 
there  is  no  disturbance  of  the  general  health. 

§  1.  Ovarian  Dropsy. — In  the  greater  number  of  cases  cysts  are 
developed  containing  fluid — ovarian  dropsy,  as  it  has  been  termed. 
By  percussion  over  the  prominent  part  of  the  abdomen,  want  of 
resonance  is  discovered,  and  fluctuation  will  be  made  out  more  or 
less  readily  in  the  same  situation,  according  to  the  stage  which  the 
disease  has  reached;  but  at  its  very  commencement  this  must  be  im- 
perceptible. In  speaking  of  ascites  (Chap.  VII.  Div.  I.  §  2,)  the 
sio-ns  derived  from  these  sources  by  which  that  disease  is  character- 
ized were  pointed  out;  we  have  now  to  notice  the  indications  which 
the  same  means  of  investigation  afford  in  cases  of  encysted  dropsy. 

A  cyst  developed  from  the  ovary  commences  to  one  side  of  the 
mesian  line,  and  consequently  for  a  long  period  during  the  conti- 
nuance of  the  case,  the  dulness  on  percussion  occupies  one  side  of 
the  abdomen  much  more  than  the  other;  fluctuation  extends  upwards 
on  that  side,  and  can  be  readily  traced  so  long  as  one  hand  does 
not  pass  far  beyond  the  umbilicus,  but  becomes  at  once  obscure  when 
it  is  placed  towards  the  flank  on  the  resonant  side.  _  When  these 
two  observations  correspond,  the  evidence  is  more  satisfactory  than 
that  derived  from  any  other  source :  sometimes  it  is  even  more 
striking  when  the  fluid  is  contained  in  several  cysts,  and  the  tumour 
is  inultTlocular.  In  such  cases  fluctuation  may  be  most  clearly  per- 
ceptible while  the  hands  are  placed  only  a  few  inches  apart,  but  be- 
comes obscure  as  soon  as  the  boundary  between  two  cysts  is  passed; 
indeed  the  position  of  the  septa,  as  they  reach  the  surface  of  the  ab- 
domen, is  sometimes  distinctly  defined.  Occasionally  the  enlarged 
ovary  very  early  assumes  a  central  position  with  reference  to  the 
viscera,  pushing  them  aside  into  both  lumbar  regions  pretty  equally, 
and  approaching  the  anterior  wall  of  the  abdomen  in  the  hypogas- 
trium ;  and  then  the  diagnosis  requires  more  care. 

As  the  disease  advances  it  gradually  encroaches  more  and  more 
on  the  whole  cavity  of  the  abdomen,  and  then  we  have  recourse  to 
other  measures  to  ascertain  that  the  fluid  is  cysted,  and  not  free  in 
the  peritoneum. 

The  principles  have  been  already  laid  down  (p.  90)  which  ought 
to  be  present  to  the  mind  in  every  case  that  comes  before  us,  and 
thev  are  equally  applicable  to  the  most  self-evident  as  to  the  most 
obscure.  Rising  out  of  the  pelvis,  as  the  diseased  ovary  does,  it  is 
very  often  possible  to  trace  in  the  lumbar  and  iliac  regions  resonant 
bowel  pushed  aside,  not  floated  upwards  upon  the  surface  of  the  fluid. 
Even  when  the  greater  part  of  the  intestines  have  been  forced  into 
the  thorax  by  the  enlargement  of  the  cyst  the  ribs  do  not  spread 
out  as  when  subjected  to  the  pressure  of  fluid  lodged  in  the  perito- 
neum, and  the  abdomen  has  a  globular  form ;  at  the  same  time, 
the  height  to  which  the  dulness  extends  is  not  equal,  but  at  some 
point  resonance  descends  far  below  the  level  to  which  the  fluid  rises 


378  DISEASES    OF    TIIE    OVARIES. 

at  another;  for  the  very  same  reasons  the  relative  position  of  dul- 
nesa  and  resonance  arc  but  little  altered  by  change  of  posture. 

At  the  risk  of  repetition  it  must  be  remarked  that  the  whole  of  the  facts  upon 
which  oar  inductions  are  formed  may  be  resolved  into  the  simple  effects  of  the 
laws  of  gravitation,  as  modified  by  the  circumstance  of  the  fluid  being  free  in  the 

p  iritoneum,  or  confined  in  a  cyst,  and  the  intestine,  which  is  specifically  lighter, 
being  at  liberty  to  float  on  its  surface  or  not.  Hence,  in  applying  the  fact  of  re- 
sonance being  observed  below  the  fluid  level,  or  even  in  the  groin,  we  must  be 
Careful  that  it  is  not  caused  by  a  portion  of  the  intestine  which  is  naturally  limited 
in  its  movement,  or  one  tied  down  by  old  adhesions.  Mistakes  are  less  likely  to 
be  made  in  observing  the  effects  of  change  of  posture,  unless  the  whole  of  the  vis- 
cera are  pushed  up  under  the  ribs,  when  the  observation  may  be  difficult. 

In  mere  physical  diagnosis  those  cases  most  resemble  ovarian  dropsy  in  which 
adhesions  have  been  formed  in  consequence  of  an  attack  of  peritonitis,  by  which 
the  fluid  effused  is  as  much  limited  in  position  as  if  it  had  been  contained  in  a 
true  cyst.  In  such,  however,  the  general  symptoms,  which  are  those  of  chronic 
peritonitis,  are  much  more  severe  than  are  ever  observed  in  the  smaller  sized  ova- 
rian cysts,  which  alone  they  resemble;  and  tho  history,  if  correct,  is  wholly  differ- 
ent. The  one  commences  with  a  severe  attack,  of  which  pain  in  the  abdomen  is 
a  prominent  feature,  and  continued  uneasiness,  tenderness  on  pressure,  quick  pulse 
and  emaciation  mark  its  progress;  in  the  other,  the  commencement  of  the  disease 
is  not  marked,  pain  is  at  juo  time  severe,  and  the  general  health  is  not  much  dis- 
turbed until  it  has  lasted  for  a  long  time,  and  tapping  has  been  more  than  once 
had  recourse  to. 

When  the  cyst  is  not  very  large,  and  its  position  central,  there  are  two  condi- 
tions which  may  produce  analogous  phenomena — a  bladder  or  a  uterus  distended 
with  fluid.  In  the  former  our  necessary  inquiry  into  the  amount  of  the  urine  will 
be  answered  by  a  report  either  of  retention  or  incontinence:  no  water  passed  at 
all,  or  a  constant  overflow  from  the  paralyzed  viscus,  and  either  circumstance  is 
sufficient  to  suggest  the  employment  of  the  catheter.  Hydrometra  is  so  rare  a 
form  of  disease  that  it  may  almost  be  passed  over,  and  would  be  best  recognised 
by  vaginal  examination,  which  may  always  be  had  recourse  to  when  any  doubt  ex-* 
ists  as  to  the  nature  of  a  local  collection  of  fluid  in  the  abdomen. 

The  remarks  on  this  mode  of  investigation  must  be  reserved  till  the  diagnosis 
of  solid  ovarian  tumours  has  been  discussed. 

•§  2.  Tumours. — The  term  is  only  relative,  as  in  most  instances 
the  diseased  structure  contains  cysts  in  larger  or  smaller  collec- 
tions of  fluid;  and  in  the  earlier  stages,  those  in  -which  the  fluid  ul- 
timately accumulates  to  the  greatest  extent  are  scarcely  distinguish- 
able from  those  in  which  none  at  all  is  found:  were  the  distinction 
more  easily  made,  there  is  no  point  of  practical  importance  to  be 
gained  in  attempting  it,  except  we  have  regard  to  the  more  rapid 
growth  and  speedily  fatal  termination  of  some  of  the  forms  of  solid 
growth.  It  is  chiefly  in  these  that  symptoms  are  to  be  met  with 
such  as  have  been  already  mentioned  as  the  only  facts  in  the  his- 
tory of  ovarian  disease  which  can  call  attention  to  its  existence: 
pains  in  the  groins,  a  sense  of  weight  and  bearing  down  among  the 
pelvic  viscera,  constipation,  haemorrhoids,  and  painful  defecation; 
occasionally,  too,  the  functions  of  the  bladder  are  interfered  with, 
but  this  chiefly  occurs  at  a  later  period,  when  the  tumour  rises  out 
of  the  pelvis.  During  its  growth,  occasional  attacks  of  more  severe 
pain  may  take  the  place  of  the  constant  dragging  sensation,  and  as 
this  may  imply  that  the  sensation  is  excited  by  local  peritonitis,  and  is 


TUMOURS.  379 

not  the  mere  pain  of  abnormal  growth,  the  observation  would  be  of 
importance  if  the  question  of  excision  were  ever  entertained. 

When  felt  above  the  pubis,  the  surface  of  a  solid  tumour  is  seldom 
perfectly  uniform,  especially  when  it  is  one  of  rapid  growth ;  the 
feeling  of  elasticity  is  sometimes  closely  allied  to  the  sense  of  fluc- 
tuation, when  the  latter  is  obscured  by  the  depth  at  which  the  fluid 
is  placed  beneath  the  parietes  and  the  thickness  of  the  walls  or  the 
multitude  of  the  cysts.  Before  it  can  be  reached  in  this  situation 
it  must  already  have  acquired  some  size,  and  therefore  it  cannot 
very  well  be  confounded  with  fibrous  tumour  of  the  uterus:  its  mo- 
bility will  distinguish  it  from  chronic  matting  together  of  the  tissues 
by  local  peritonitis;  and  its  deep  connexions  leave  no  room  for  the 
supposition  that  it  is  attached  to  the  bone3  of  the  pelvis:  at  the  same 
time,  it  is  distinguished  from  omental  growths,  or  malignant  enlarge- 
ment of  abdominal  glands,  by  our  being  able  to  trace  it  under  fa- 
vourable circumstances  down  into  the  pelvis.  No  certain  conclu- 
sion can  be  arrived  at  if  the  abdominal  walls  be  tense  and  resisting; 
but  when  the  patient  is  placed  in  a  proper  position,  and  the  resis- 
tance can  be  overcome  by  gradual  pressure,  the  practitioner  can  al- 
ways place  his  hand  between  the  brim  of  the  pelvis  and  the  growth, 
when  not  ovarian,  and  cannot  do  so  when  the  seat  of  the  disease  is 
the  ovary  itself. 

The  position  of  the  tumour  generally  determines  that  it  is  not  due  to  pregnancy 
in  its  ordinary  form:  the  exceptions  are  when  the  tumour  is  central,  or  the  preg- 
nancy is  tubal.  The  distinction  in  these  cases  must  depend  almost  entirely  on  the 
absence  or  presence  of  other  signs  of  pregnancy,  and  it  is  to  be  remembered  that 
the  two  conditions'may  coexist,  and  nothing  is  lost  by  waiting  for  the  termination 
of  gestation  before  pronouncing  a  definite  opinion.  In  place  of  giving  an  elabo- 
rate account  of  the  signs  of  pregnancy,  which  does  not  come  into  our  classifica- 
tion, I  would  refer  my  readers  to  the  treatises  especially  devoted  to  this  subject, 
only  remarking  that  this  question,  perhaps  more  than  any  other,  calls  for  the  ex- 
ercise of  common  sense.  The  history  is  full  of  instruction,  if  rightly  read^  the 
time  of  the  cessation  or  alleged  irregularity  of  menstruation,  and  its  assigned 
causes,  compared  with  the  appearance  of  the  patient,  with  regard  to  size,  aspect, 
manner,  carriage,  &c,  give  the  practitioner  hints  that  need  not  be  quite  disregarded, 
even  when  he  is  told  of  the  casual  recurrence  of  the  menstrual  flux;  or  if  in  an 
exceptional  case,  menstruation  were  irregular  at  the  time  of  conception,  or  have 
persisted  regularly  since,  the  sum  of  the  signs  from  the  breast,  from  the  abdomen, 
and  from  the  tactus  eruditus  per  vaginam,  are  sufficient  for  his  guidance  if  taken 
together.  Perhaps  it  is  scarcely  stated  in  general  with  sufficient  distinctness  that 
the  colour  of  the  areola  is  of  much  less  moment  than  the  development  within  it  of 
the  glandular  follicles.  It  has  been  asserted  that  the  fluid  which  so  frequently 
oozes  from  the  mamma  presents  under  the  microscope  all  the  appearance  of  milk 
in  cases  of  pregnancy.  The  result  of  my  experience  convinces  me  that  the  unde- 
fined fulness  of  the  abdomen,  and  the  feeling  of  solidity  perceived  in  pregnancy, 
is  never  exactly  simulated  by  enlargement  from  any  other  cause.  The  sound  of 
the  fcetal  heart  is  unquestionably  the  most  conclusive  evidence,  but  it  is  often  diffi- 
cult, and  sometimes  impossible,  to  discover  it. 

Digital  examination  detects  in  the  early  stages  of  ovarian  disease, 
a  tumour  to  one  side  and  at  the  back  of  the  vaginal  wall, — moveable, 
but  independent  of  the  movement  of  the  os  uteri,  which  at  this  pe- 
riod retains  its  normal  position.     As  the  ovary  enlarges,  the  uterus 


380  DISEASES   OF   THE    OVARIES. 

maybe  somewhat  pushed  down ;  at  a  later  period  it  is  drawn  up,  and 
the  neck  is  sometimes  most  remarkably  elongated.  The  mobility 
of  the  mass  and  its  regular  form,  as  perceived  in  this  examination, 
are  the  points  which  especially  distinguish  it  from  the  matting  to- 
gether of  tissues  which  is  produced  by  local  peritonitis  of  a  chronic 
form  ;  and  the  elongation  of  the  neck  of  the  uterus,  when  any  change 
occurs  there,  proves  that  the  enlargement  is  not  a  consequence  of 
pregnancy. 


381 


CHAPTER  XXXIII. 


DISEASES    OF    THE    UTERUS. 


§  1,  Amenorrhea — §  2,  Menorrhagia — §  3,  Leucorrhcea —  Vaginitis 
— §  4,  Tumours — fibrous — polypous — §  5,  Prolapsus — Malposi- 
tion— §  6,  Congestion — Ulceration — §  7,  Cancer. 

There  is  but  little  to  be  said  on  the  diagnosis  of  this  class  of 
diseases,  ■which  are  perhaps  legitimately  regarded  as  a  special  de- 
partment of  practical  medicine:  but  in  the  very  fact  of  a  speciality 
there  is  a  tendency  to  abuse,  and  unfortunately  persons  are  always 
to  be  found  who  will  use  any  pretext  to  enrich  themselves  at  the 
expense  of  their  patients,  without  regard  to  morality  or  propriety. 
A  professional  sect  has  grown  up  in  England  in  consequence  of  the 
minute — the  needlessly  minute  investigations  of  the  accoucheurs  of 
France,  which,  impelled  by  such  motives,  assumes  to  itself,  under 
the  guise  of  this  spe"eialite,  the  management  of  all  the  diseases  of 
the  female  sex;  rightly  or  wrongly,  with  reason  or  without  reason, 
referring  them  all  to  changes  in  the  uterus.  Diseases  are  spoken 
of  as  of  frequent  or  constant  occurrence  which  we  search  for  in 
vain,  except  in  a  very  few  instances,  in  the  dead  body.  In  reality, 
small  as  is  our  list  of  local  maladies  connected  with  the  uterus  and 
vagina,  even  these  are  mainly  due  to  constitutional  causes,  and  are 
best  met  by  constitutional  remedies. 

§  1.  Amenorrhoea. — Absence  of  the  catamenia  must  be  distin- 
guished from  chlorosis,  inasmuch  as  tardy,  scanty,  painful  and  sup- 
pressed, menstruation  are  very  often  found  altogether  independent 
of  general  signs  of  anaemia;  the  face  may  be  florid,  the  pulse  good, 
the  body  well  nourished,  and  the  general  health  fair,  notwith- 
standing the  coexistence  of  amenorrhoea.  Perhaps  all  this  indi- 
cates a  condition  of  local  as  well  as  general  congestion  which  inter- 
feres with  the  due  performance  of  the  function,  but  quite  as  often 
the  aspect  of  the  patient  is  fallacious,  and  the  real  condition  is 
atonic,  the  colour  of  the  face  being  the  effect  of  venous  congestion 
rather  than  of  general  plethora.  This  is  proved  not  only  by  the 
coldness  and  clamminess  of  the  hands  and  feet,  but  by  the  fact  that 
the  menstrual  functions  become  regular  under  the  judicious  em- 
ployment of  tonics,  and  that  if  they  be  not  regulated,  chlorosis  will 
speedily  supervene. 

When  dependent  on  local  causes,  total  absence  of  the  secretion 
may  persist  through  life;  or  the  fluid,  unable  to  find  an  outlet,  may 
accumulate  in  the  uterus  and  vagina:  in  each  of  these  there  is  some 
defect  of  organization.     In  other  instances,  exposure  to  cold  ex- 


882  DISEASES    OF   THE    UTERUS. 

cites  probably  to  the  first  place  congestion  of  the  uterus,  and  so 
brings  on  Budden  suppression;  but,  if  the  function  be  not  speedily 
restored  a  constitutional  state  is  developed,  and  the  disorder  loses 
its  local  character. 

Though  so  intimately  connected  with  age,  the  function  is  really 
dependent  on  the  development  of  organs  which  age  implies,  and 
therefore  in  cases  of  retarded  menstruation  we  have  to  look  to  the 
girlish  or  womanly  appearance  of  the  patient  before  interfering 
with  the  uterus;  while,  in  the  absence  of  the  catamenia  after  mid- 
life, we  have  to  remember  that  the  involution  of  the  uterus  and 
ovaries  takes  place  much  earlier  in  some  females  than  others.  Sup- 
pression for  a  time  almost  always  follows  after  an  attack  of  any 
severe  disease,  and,  if  the  individual  have  attained  a  certain  age, 
may  be  persistent. 

In  amenorrhcea  which  is  not  accompanied  by  anocmia  we  must 
always  remember  the  possible  coexistence  of  pregnancy:  this  sus- 
picion is  more  likely  to  be  just  if  previously  the  catamenia  were 
always  regular,  and  is  proportionally  less  probable  if  they  have 
been  irregular  in  their  appearance. 

Irregular  menstruation  is  only  to  be  regarded  as  a  symptom  of  constitutional  dis- 
turbance, and  not  as  a  local  disorder.  The  catarnenial  periods  are  then  often  at- 
tended with  pain;  dysmenorrhea  is  sometimes  also  complained  of  when  the  flux 
is  regular,  but  scanty  or  pale:  in  all  of  these  the  disorder  is  unquestionably  de- 
pendent on  constitutional  causes.  The  pain  in  such  cases  is  probably  neuralgic,  as 
it  is  associated  with  other  sensations  of  an  analogous  kind,  head-ache,  back  ache, 
&c:  it  generally  precedes  the  menstruation,  and  is  most  intense  at  the  commence- 
ment of  the  discharge. 

In  other  instances  painful  menstruation  is  accompanied  by  no  diminution,  but 
perhaps  by  excess  of  the  catamenia,  and  may  be  connected  with  hemorrhoids, 
loaded  bowels,  &c,  or  with  other  diseases  of  the  uterus,  irritability,  tenderness, 
fibrous  tumours,  &c.  Sometimes  the  function  is  wholly  deranged,  and  coagula 
are  discharged  in  place  of  the  ordinary  fluid,  or  it  is  mixed  with  membranous 
shreds.  We  have  no  knowledge  of  the  pathological  causes  of  these  states,  and 
must  be  content  with  the  explanation  which  disordered  function  conveys. 

I  think  we  must  be  cautious  in  admitting  the  possibility  of  a  contracted  state  of 
the  orifice  as  a  cause  of  dysmenorrhcea.  Dilatation  at  all  events  constantly  fails 
in  relieving  it. 

§  2.  Menorrhagia* — This  term  does  not  include  occasional  he- 
morrhage, but  must  be  restricted  to  the  undue  persistence  and  the 
too  frequent  recurrence  of  regular  menstruation.  It  is  most  com- 
monly dependent  on  some  general  state  of  system ;  rarely  produced 
by  plethora,  it  is  much  more  frequently  due  to  impoverished  blood: 
hence  it  is  seen  in  disease  of  the  kidney  or  in  general  debility,  in- 
creasing the  anaemia  which  accompanies  these  conditions. 

Sometimes  it  is  the  consequence,  of  undue  excitement  of  the  sex- 
ual organs :  and  it  is  not  an  uncommon  consequence  of  the  imper- 
fect return  of  the  uterus  to  its  normal  state  after  tedious  labour  or 
miscarriage. 

Occasionally  hemorrhage  very  closely  resembles  menorrhagia 
when  it  comes  on  at  regular  intervals,  and  these  are  determined  by 


LEUCORRHCEA.  383 

the  congestion  or  whatever  else  it  is  that  gives  rise  to  the  monthly 
return  of  the  menses ;  but  hemorrhage  means  something  more  than 
mere  excess  of  the  natural  flux.  It  is  associated  either  with  de- 
struction of  surface,  or  with  polypous  or  fibrous  growth,  or  with 
irregular  position  of  the  placenta  in  pregnancy;  sometimes  it  ap- 
pears during  the  early  periods  of  pregnancy,  simulating  irregular 
rather  than  excessive  menstruation:  in  all  cases,  sooner  or  later, 
hemorrhage  ceases  to  wear  the  aspect  of  regularity,  and  its  regular 
appearance  is  the  best  indication  that  it  is  not  menorrhagia. 

§  3.  Leueorrhcea. — This  disorder  is  nothing  more  than  an  exces- 
sive secretion  of  the  natural  mucus  which  lubricates  the  passage. 
Attempts  have  been  made  by  discriminating  the  especial  characters 
of  the  secretion,  to  determine  whether  it  comes  from  the  uterus  or 
the  vagina.  These  facts  may  be  interesting  as  curious  pathological 
researches,  but  they  are  of  no  value  in  practice:  whatever  restores 
the  tone  of  the  system  at  large,  and  along  with  that  gives  a  healthy 
character  to  the  mucous  lining  of  the  generative  organs,  relieves 
leueorrhcea;  local  remedies  may  aid  in  its  removal,  but  alone, 
though  they  check  it  for  a  time,  they  leave  the  cause  of  the  dis- 
order untouched.  It  is  not  a  true  catarrh,  and  this  it  is  which  best 
distinguishes  it  from  gonorrhoea:  the  latter  begins  with  irritation, 
possibly  painful  micturition,  which  is  soon  followed  by  a  copious  se- 
cretion of  thick  puriform  matter,  and  this  at  length  assumes  the 
character  of  a  thin  discharge  which  cannot  be  distinguished  from 
leueorrhcea ;  it  is  the  history  alone  that  enables  us  to  determine  in 
cases  of  long  standing  which  disorder  is  present. 

In  children  true  catarrh  of  the  vagina,  vaginitis  as  it  is  called, 
is  not  uncommon.  It  attacks  the  very  same  individuals  who  are 
from  cachexia  liable  to  ulcerations  of  the  mouth,  to  excessive  im- 
petiginous eruptions  with  copious  purulent  discharges;  and  like 
them  is  manifestly  constitutional.  It  has  often  given  rise  to  un- 
founded suspicions  and  charges  of  crime,  but  there  ought  not  to  be 
any  doubt  in  a  medico-llgal  point  of  view,  because  of  the  absence 
of  bruises  or  local  injury;  there  are  no  signs  of  inflammation  pre- 
sent except  a  degree  of  soreness  or  irritation  of  the  surrounding 
skin  from  the  purulent  secretion  lodging  upon  it.  It  may  be  de- 
pendent on  the  presence  of  ascarides. 

"Whenever  vaginal  discharge  is  spoken  of,  we  ought  to  ascertain  whether  it  be 
at  all  offensive,  because  it  may  be  induced  by  cancerous  disease :_  if  blood-tinged 
at  other  than  the  monthly  periods,  it  is  not  improbable  that  it  is  dependent  on 
commencing  scirrhus. 

Leueorrhcea  is  so  uniformly  connected  with  causes  independent  of  the  uterus 
itself,  that  its  associations  demand  general  investigation  much  more  than  its  amount 
or  its  other  peculiarities.  It  is  found  with  an  anaemic  state,  with  a  flabby  and  re- 
laxed habit,  or  with  a  condition  of  the  rectum  which  excites  irritation  of  the  uterus 
or  vao-ina.  Upon  a  correct  knowledge  of  these  relations  depends  the  successful 
treatment  of  the  disease,  and,  on  the  other  hand,  the  knowledge  of  its  existence 
serves  to  make  us  acquainted  with  the  habit  of  a  patient  who  may  be  seeking  re- 


384  DISEASES    OF    THE    UTERUS. 

lief  for  other  disorders,  or  to  the  detection  of  derangement  of  health  which  might 
Otherwise  be  overlooked. 

§  4.  Tumours. — It  is  unnecessary  in  such  a  short  summary  to 
separate  the  fibrous  and  the  polypous  tumours,  because  their  re- 
co'Tiiition  is  almost  wholly  a  question  for  the  professed  accoucheur. 
They  are  both  frequently  marked  by  the  recurrence  of  occasional 
hemorrhage,  by  bearing  down,  sense  of  pain  and  weight,  &c,  which 
call  attention  to  the  condition  of  the  uterus  itself.  A  fibrous  tu- 
mour may  often  be  felt  through  the  abdominal  walls,  just  at  the 
brim  of  the  pelvis,  when  it  is  situated  in  the  body  of  the  organ : 
its  central  position  and  its  elevation  serve  to  distinguish  it  from 
commencing  ovarian  tumour:  polypous  growths  can  only  be  de- 
tected by  examination  per  vaginam. 

Both  diseases  may  continue  for  a  long  period  without  the  possibility  of  their 
being  actually  traced.  We  infer  the  probability  of  polypus  when  occasional  he- 
morrhage is  accompanied  by  constant  leucorrhcca,  and  a  sense  of  bearing  down; 
when,  at.  the  same  time,  the  os  uteri  is  partly  open,  and  there  is  no  hardness  or 
irregularitj  of  its  lips.  A  fibrous  tumour,  again,  may  be  suspected  when  there  is 
menorrhagia  unconnected  with  general  disorder,  or  traceable  alteration  of  parts, 
and  which  has  not  been  attended  with  pain;  and  when,  in  course  of  time,  this  is 
followed  by  discomfort  in  micturition,  or  by  bearing  down  pains  and  efforts  at  ex- 
pulsion. 

§  5.  Prolapsus. — The  sense  of  weight  and  bearing  down  is  con- 
stantly produced  by  actual  displacement  of  the  womb.  The  history 
very  generally  dates  from  previous  pregnancy,  when  the  patient 
got  up  too  soon,  or  continued  in  an  enfeebled  state  at  the  time 
when  she  was  allowed  to  get  up:  the  ligaments  fail  to  retain  the 
organ  in  its  proper  place,  and  it  falls  by  its  own  weight.  Some- 
times in  women  who  have  never  borne  children  an  unusual  tension 
of  the  abdominal  walls,  by  strain  or  violent  effort,  may  cause  de- 
scent of  the  uterus,  just  as  it  may  cause  hernia.  Occasionally  it 
is  produced  by  the  constant  carrying  of  heavy  weights :  the  fact  is 
only  to  be  ascertained  by  examination. 

Of  late  years  we  have  heard  a  great  deal  of  form#f  prolapsus,  which  very  often 
exist  only  in  the  mind,  perhaps  we  may  venture  to  say,  in  the  mouth  of  the  prac- 
titioner,— ante-version,  retro-version— ante-flexion,  retro-flexion;  the  former  imply- 
ing a  displacement  of  the  whole  organ,  the  latter,  that  its  body  becomes  flexed  or 
bent  on  itself.  No  doubt  retro-version  does  occasionally  occur,  as  a  very  painful 
and  annoying  form  of  displacement,  pressing  upon  and  greatly  interfering  with  the 
action  of  the  rectum:  ante-version  must  be  a  very  rare  condition  considering  the 
daily  and  hourly  distention  of  the  bladder,  which  lies  in  front  of  the  uterus.  Ante- 
flexion, as  has  been  pointed  out  by  some  French  physiologists,  is  the  natural  form 
of  the  womb  in  early  life,  and  though  it  may  continue  abnormally  after  pregnancy, 
or  may  be  even  exaggerated,  it  seems  absurd  to  assign  any  importance  to  it  except 
when  aggravated  by  the  existence  of  a  tumour,  or  abnormally  fixed  by  peritoneal 
adhesion.     Retro-flexion  is  the  most  unimportant  among  the  changes  of  position. 

Prolapsus  may  be  limited  to  the  walls  of  the  vagina,  or  they  may 
be  involved  in  the  descent  of  the  womb.  This  often  gives  rise  to 
more  annoyance  to  the  patient  in  walking  or  making  any  exertion 
than  prolapsus  uteri  when  free  from  such  a  complication.     One  of 


CONGESTION    AND    ULCERATION.  385 

its  most  prejudicial  consequences  is  when  a  portion  of  the  bladder 
descends  into  the  interior  of  the  fold  of  mucous  membrane,  render- 
ing it  impossible  to  evacuate  its  contents  completely:  the  same  se- 
quence of  events  occurs  as  when  the  bladder  is  paralyzed;  the  urine 
decomposes,  irritation  of  the  bladder  is  set  up,  unhealthy  mucus  is 
secreted,  and  chronic  cvstitis  is  established. 

Valuable  information  in  regard  to  diagnosis  is  also  gained  from 
an  opposite  condition,  when  the  os  uteri  is  found  unusually  high  up. 
It  is  constant  in  pregnancy  after  the  fourth  month:  it  is  often 
found  when  there  has  been  local  inflammation  of  the  surrounding 
tissues :  and  it  affords  one  of  the  most  complete  contrasts  between 
large  ovarian  dropsy  and  ascites,  because  in  the  latter  the  uterus 
is  always  depressed. 

§  6.  Congestion  and  Ulceration. — A  very  prominent  place  has 
been  given  by  certain  practitioners  to  inflammation  and  ulceration 
of  the  os  and  cervix  uteri:  yet  they  are  comparatively  rare,  and,  as 
substantive  diseases,  unimportant.  They  do  indeed  accompany  other 
conditions  which  may  be  of  serious  moment  to  the  health  of  the 
patient,  but  in  their  uncomplicated  form  their  ephemeral  notoriety 
will  ere  long  have  passed  away ;  true  pathology  and  useful  practice 
have  been  neither  advanced  nor  benefited  by  those  who  have  made 
them  their  study:  and  posterity  will  regard  very  differently  the  in- 
ventor of  the  stethoscope  and  the  speculum. 

Simple  congestion  may  be  the  consequence  of  over-excitement,  or 
of  sudden  suppression  of  the  catamenia;  it  may  be  excited  by  irri- 
tation of  the  rectum,  or  it  may  be  only  an  exaggeration  of  that 
normal  condition  which  produces  the  menstrual  discharge :  it  is  often 
associated  with  tumours  of  the  uterus,  or  with  prolapsus  of  the  or- 
gan. After  repeated  pregnancy,  enlargement,  fissure,  or  irregu- 
larity of  the  os  uteri  may  be  often  detected,  to  which  the  name  of 
congestion  is  evidently  inapplicable;  but  sometimes  enlargement  of 
the  whole  organ  continues  after  delivery,  and  a  state  of  venous 
congestion  is  maintained,  which  may  result  in  hypertrophy  or  indu- 
ration. 

Inflammation,  as  applied  to  a  muscular  structure,  is  generally  a 
misappropriation  of  language;  the  event  we  know  to  be  a  rare  one. 
When  acute  or  subacute  symptoms  are  present,  their  true  source  is 
in  the  mucous  membrane  which  lines  its  interior,  or  the  serous  layer 
which  encloses  the  womb  and  its  appendages.  Such  circumstances 
occur  as  a  consequence  of  the  puerperal  state,  and  there  is  no  more 
frequent  cause  of  partial  peritonitis:  (see  Chap.  XXVIII.,  §  1,  a:) 
they  are  also  developed  occasionally  in  females  with  irregular  men- 
struation;  and  the  lining  membrane  of  the  uterus  has  been  some- 
times inflamed  by  the  presence  of  the  gonorrhoeal  poison. 

What  has  been  called  ulceration  is  generally  only  an  aphthous  or 
granular  condition  of  the  mucous  membrane,  and  depends  simply 
on  constitutional  causes:  very  often  a  patch  of  adhering  mucus  has 
25 


386  DISEASES    OF    THE    UTERUS. 

been  mistaken  for  an  ulcer;  sometimes  it  is  only  a  creation  of  the 
fancy;  perhaps  occasionally  the  result  of  excessive  leucorrhcea;-  it 
is  then  but  a  symptom,  and  a  very  minor  one.  True  ulceration  is 
almost  certain  to  be  either  a  development  of  scrofula,  the  result  of 
cancerous  disease,  or  of  syphilitic  poison.  If  none  of  these  causes 
be  present,  we  may  safely  regard  the  ulceration  as  of  no  conse- 
quence in  so  far  as  it  is  a  local  malady. 

The  states  of  winch  we  have  just  spoken  are  described  as  giving  rise  to  a  very 
great  variety  of  symptoms;  but  with  the  exception  of  the  feeling  of  weight  and 
sense  of  tenderness  which  are  the  real  exponents  of  congestion,  the  relations  have 
been  found  to  be  wholly  casual.  By  carefully  recorded  observations  it  lias  been 
ascertained  that  the  excess  and  diminution  of  the  menstrual  flux,  the  leucorrhocal 
discharges,  the  varied  sensations  and  imaginings  of  hysteria  were  quite  as  fre- 
quently traceable  in  cases  which  presented  none  of  those  characters  which  are  said 
to  mark  "inflammation  and  ulceration  of  the  os  uteri"  as  in  cases  in  which  the 
advocates  of  this  new  nosology  would  have  discovered  the  more  direct  signs  of  its 
presence.  That  these  signs  do  indicate  any  important  condition  is  probably  a 
false  inference,  but  that  the  other  symptoms  of  which  we  have  spoken  are  in  any 
way  excited  by  it,  is  absolutely  disproved. 

Tenderness  to  the  touch,  while  very  probably  indicating  congestion,  must  at 
times  be  regarded  as  rheumatic,  or  neuralgic,  because  of  the  absence  of  any  thing 
else  indicating  inflammatory  action,  and  one  of  our  first  principles  of  diagnosis  is, 
that  pain  and  tenderness  are  not  to  be  regarded,  when  standing  alone,  as  evidence 
of  inflammatory  action.  Induration,  perceptible  hardness  of  the  neck  of  the 
womb,  is  generally  to  be  viewed  as  a  consequence  of  past  inflammatory  action  of 
some  kind  or  other;  but  when  accompanied  by  irregularity  of  surface,  it  is  one 
of  the  early  indications  of  cancer. 

§  7.  Cancer. — Nearly  all  the  symptoms  of  uterine  disorder  -which 
have  occupied  our  attention  may  be  excited  by  the  commencement 
or  progress  of  malignant  disease;  monorrhagia,  or  true  hemorrhage, 
painful  menstruation,  leucorrhoeal  discharge,  sensations  of  discom- 
fort, uneasiness,  and  bearing-down,  as  well  as  true  pain,  are  each 
to  be  found  in  various  instances.  In  its  advanced  stages  no  one  who 
supposes  himself  at  all  conversant  with  the  evidences  of  uterine 
disease  ought  to  have  any  difficulty  in  recognising  it.  The  wan  and 
unhealthy  aspect  of  the  patient  and  the  odour  of  the  disease  may 
reveal  it  without  the  need  of  asking  a  question;  if  it  have  made 
less  progress,  the  existence  of  pain,  of  occasional  hemorrhage,  of 
constant  discharge,  which  has  very  often  a  peculiar  colour,  or  may 
have  to  the  patient's  own  consciousness  a  disagreeable  odour,  partial 
emaciation  and  sallowness  are  its  usual  characters.  But  any  or  all 
of  these  symptoms  may  be  partially  or  wholly  absent,  especially  at 
the  commencement  of  the  disease:  it  may  cause  no  pain,  no  hemor- 
rhage, no  discharge  differing  from  leucorrhcea,  no  emaciation  or 
malignant  aspect.  Digital  examination  will  detect  the  roughness, 
irregularity,  or  hardness  of  commencing  cancer  with  more  certainty, 
and  tit  earlier  periods,  than  ocular  examination  with  the  speculum. 
But  is  examination  often  or  always  to  be  resorted  to?  To  this 
question  I  would  reply  that  we  must  be  on  our  guard  against  the 
fancied  excellence  of  accurate  diagnosis,  remembering  that  it  is  our 


CANCER.  387 

business  to  treat  disease,  not  to  be  supremely  wise :  one  examination, 
when  desired  by  the  patient  or  her  friends  for  their  information,  can 
do  no  harm ;  repeated  examinations  can  do  no  good.  We  may  con- 
clude, with  every  probability  of  truth,  that  in  such  indistinct  cases 
the  persons  who  think  most  and  talk  most  of  the  state  of  their 
uterine  organs  have  nothing  really  the  matter:  if  by  examination 
we  have  discovered  what  we  deem  the  indication  of  commencing 
scirrhus,  the  information  can  be  of  little  practical  use ;  the  know- 
ledge is  unquestionably  of  value,  but  we  can  neither  make  use  of  it 
to  arrest  a  disease  which  we  believe  incurable,  nor  to  warn  the  pa- 
tient of  impending  danger,  when  our  convictions  are  not  quite  eer- 
tain.  By  a  little  delay  the  symptoms  become  more  pronounced,  the 
examination  more  called  for,  and  the  result  more  certain ;  in  the 
early  stages  of  disease,  it  is  therefore  unwise  to  press  for  it,  if  we 
mean  to  act  as  honourable  members  of  the  profession.  A  digital 
examination  ought  always  to  precede  the  use  of  the  speculum,  which 
may  be  productive  of  much  mischief  if  introduced  in  cases  of 
cancer. 


388 


CHAPTER  XXXIV. 

DISEASES    OF   THE    BONES,  JOINTS,  AND   MUSCLE?. 

Div.  I. — Diseases  of  Bones  and  Joints — their  Constitutional  Cha- 

racter — Periost  it  is —  TtacTi  it  is — Mollit  ies — Frag  ilitas. 
Div.  II. — Diseases  of  31uscles. 

Division  I. — Diseases  of  Bones  and  Joints. 

The  more  important  points  with  reference  to  diseases  of  the  joints 
have  been  already  mentioned  (Chap.  V.,  §  4,)  and  it  is  only  in  their 
relation  to  rheumatism  that  they  can  become  the  subjects  of  medi- 
cal diagnosis.  Their  local  management  is  referred  to  the  depart- 
ment of  surgery,  and  probably  for  this  reason  they  are  not  regarded 
as  legitimately  belonging  to  the  practice  of  medicine:  but  in  fact 
they  are  almost  invariably  associated  with  depraved  constitutional 
states,  and  must  be  met  by  remedies  addressed  to  the  system  at 
large ;  in  this  view  much  of  the  knowledge  regarding  their  treatment 
must  spring  from  an  acquaintance  with  the  characters  by  which 
these  conditions  are  recognised. 

In  very  many  cases  the  disease  which  has  become  located  in  the 
joint,  from  whatever  cause  it  may  have  been  originally  derived,  is 
beyond  the  aid  of  remedies:  structures  have  been  removed,  or  ma- 
terially altered  in  their  minute  organization,  and  new  formations 
have  been  added,  which  can  no  longer  be  modified  by  treatment 
suited  to  the  primary  disease:  even  surgery  is  unable  to  offer  any 
material  relief.  These  changes  sometimes  serve  as  landmarks  by 
which  we  are  enabled  to  define  more  exactly  the  nature  of  a  subse- 
quent attack.  We  recognise  gout  by  its  tophaceous  deposits,  as  they 
are  called;  and  rheumatic  gout  by  chronic  thickening  of  the  liga- 
ments and  distortion  of  the  joints;  and  we  feel  greater  certainty 
tlfat  the  case  is  one  of  simple  rheumatism  when  all  traces  of  previ- 
ous suffering  have  disappeared:  in  cases  of  repeated  seizures,  the 
symptoms  tend  to  become'  less  and  less  distinctive  of  the  special 
malady,  and  to  present  a  certain  similarity  of  character. 

Inflammation  of  bone,  whether  ending  in  suppuration  or  in  ne- 
crosis or  caries,  belongs  entirely  to  the  surgeon,  because  local  treat- 
ment and  operative  interference  are  constantly  demanded.  Perios- 
titis, according  to  its  origin,  is  regarded  either  as  medical  or  surgi- 
cal. It  often  has  a  distinctly  rheumatic  character ;  but  it  is  still 
more  frequently  syphilitic.  It  consists  of  a  local  enlargement  on 
the  surface  of  the  bone,  tense  and  tender,  very  generally  smooth, 
but  sometimes  also  irregular,  interfering  more  or  less  with  voluntary 
motion,  because  of  its  relations  to  the  origin  or  insertion  of  muscles, 


DISEASES  OF  BONES  AND  JOINTS.  389 

but  not  hindering  passive  movement,  unless  its  position  be  in  close 
proximity  to  the  joint;  these  characteristics  point  very  plainly  to 
periosteal  inflammation.  When  the  acute  stage  is  past,  or  when  the 
affection  has  come  on  more  gradually,  the  thickening  and  indura- 
tion may  be  accompanied  by  very  little  pain.  Its  relation  to  se- 
condary syphilis  is  so  constant  that  the  discovery  of  nodes  is  very 
often  sufficient  to  guide  our  determination  in  an  obscure  case:  their 
most  common  situation  is  on  the  front  of  the  tibia,  and  next  in  fre- 
quency over  the  cranium. 

In  all  affections  of  the  bones  and  joints  in  which  motion  is  interfered  with,  we 
have  to  bear  in  mind  the  remarks  already  made  upon  posture  and  gait,  and  upon 
active  and  passive  motion:  these  modes  of  examination  serve  to  point  out  the 
various  conditions  of  stiffness  or  immobility,  of  pain  produced  by  the  muscular 
effort,  and  of  pain  produced  by  the  motion  of  diseased  surfaces  on  each  other,  or 
by  the  stretching  of  inflamed  ligaments;  distinguishing  them  from  muscular  para- 
lysis. Loss  of  power  is  the  usual  complaint  of  the  patient,  when  the  condition 
consists  really  of  inability  to  use  the  power  which  exists. 

Rachitis  is  essentially  a  disease  of  childhood,  and  is  only  known 
by  the  deformities,  whether  permanent  or  transient,  to  which  it  gives 
rise.  In  middle  life,  somewhat  analogous  effects  result  from  molli- 
ties  ossium,  though  pathologically  the  diseases  are  different;  in  the 
one  the  bones  bend,  but  do  not  break,  in  the  other  there  is  generally 
a  great  tendency  to  spontaneous  fracture.  The  fragility,  fragilitas 
ossium,  as  it  used  to  be  called,  is,  on  the  other  hand,  more  closely 
allied  to  atrophy,  and  is  very  generally  a  disease  of  old  age,  when 
the  absorption  of  tissue  exceeds  its  reproduction. 

In  rickets  and  in  mollifies  ossium  the  earthy  constituents  of  bone  are  dimi- 
nished, but  their  different  characters  are  caused  by  the  circumstance  that  in  one  the 
bone-earth  is  not  deposited  in  sufficient  quantity  to  meet  the  requirements  of  growth, 
in  the  other  it  is  removed  after  its  deposition,  and  is  replaced  by  morbid  structure: 
the  one  is  rather  a  consequence  of  faulty  nutrition,  the  other  is  the  effect  of  actual 
disease.  In  atrophy  the  fibrous  material  is  removed  as  well  as  the  lime;  and  hence, 
while  in  mollities  the  remaining  portion  of  earthy  structure  is  crushed  and  splin- 
tered by  the  bending  of  the  bone,  in  fragilitas  the  bone  itself  breaks  across. 

Division  II. — Diseases  of  Muscles. 

The  diseases  of  muscular  structure  are  not  numerous,  or  of  much 
importance:  those  chiefly  concern  us,  in  medical  practice,  which 
lead  to  paralysis,  more  or  less  complete.  One  of  the  most  common 
is  that  which  has  been  already  traced  in  connexion  with  lead  poi- 
soning (Chap.  VI.,  Div.  I.,  §  3.)  It  is  in  great  measure  limited  to 
the  extensors  of  the  fore-arm,  and  is  especially  recognised  by  the 
blue  line  round  the  gums,  which  can  always  be  traced  when  the  sys- 
tem is  impregnated  with  the  mineral.  Another  condition,  which  is 
perhaps  of  greater  importance,  is  that  in  which  the  true  muscular 
fibre  becomes  replaced  by  fat,  fatty  degeneration  is  very  frequently 
discovered  in  the  walls  of  the  heart,  rendering  its  action  feeble,  and 
materially  shortening  existence  by  its  effects  on  the  circulation.  In 
the  voluntary  muscles  the  same  change  is  occasionally  observed; 


• 


390  DISEASES    OF    BONES    AND    JOINTS. 

and  in  the  absence  of  direct  evidence  of  its  existence  it  may  be  ex- 
fcremely  difficult  to  determine  whether  the  resulting  paralysis  be 
caused  by  want  of  muscular  power  or  of  nervous  energy;  the  only 
rule  that  can  be  applied  to  distinguish  them  is,  that  when  the  dis- 
ease is  in  the  nervous  system,  the  paralyzed  muscles  all  derive  their 
energy  from  the  same  source ;  or  if  their  sources  be  different,  the 
muscles  which  are  supplied  by  distal  nerves  on  the  same  side  of  the 
body  are  always  involved  in  paralysis  affecting  those  which  receive 
their  nerves  from  a  point  nearer  to  the  brain.  When  the  paralysis 
is  caused  by  disease  of  muscle,  the  same  law  does  not  hold  good. 
On  the  other  hand,  it  must  be  remembered  that  atrophy  of  muscle 
is  a  consequence  of  loss  of  nervous  energy,  and  the  causes  of  fatty 
degeneration  are  yet  quite  unknown. 

The  muscles  are  constantly  involved  in  cellular  inflammation, 
and,  when  suppuration  follows,  the  fibres  are  bathed  in  pus,  which 
burrows  among  their  structures.  Occasionally  the  fleshy  belly  of 
the  muscle  becomes  the  site  of  small  abscesses,  but  inflammation  of 
the  fibre  apart  from  that  of  the  investing  sheath  of  areolar  tissue  is 
unknown. 


391 


CHAPTER  XXXV. 

DISEASES    OF   THE    SKIN   AND    CELLULAR  TISSUE. 

General  Principles  of  Diagnosis. — §  1,  Erythema — Urticaria — 
Roseola — §  2,  Papular  Eruptions  —  Lichen  —  Prurigo  —  §  3, 
Squamous  Eruptions — Ichthyosis — Lepra — Psoriasis — Pityri- 
as  is — §  4,  Vesicular  Eruptions — Eczema — Herpes — Scabies — §  5, 
Pustular  Eruptions — Impetigo — Ecthyma —  Acne —  Sycosis — 
§  6,  Pemphigus — Rupia — §  7,  Vegetable  Parasites — Favus — 
Porrigo  Decalvans — Pityriasis  versicolor — §  8,  Tubercle  of  the 
Skin — §  9,  Syphilitic  Eruptions — §  10,  Lupus — Scrofulous  Ul- 
cer—  Cancer  of  Skin — §  11, — Endemial Diseases  of  Skin — §  12, 
Cellular  Inflammation. 

It  is  pretty  generally  admitted  that  the  information  possessed  by 
most  practitioners  of  medicine  in  this  department  is  exceedingly 
vague:  the  lines  of  demarcation  between  the  various  forms  are  in- 
definite, and  the  results  of  treatment  for  the  most  part  unsatisfactory. 
It  is  true  that  in  general  the  diseases  of  the  skin  are  not  of  very  great 
importance,  but  it  is  an  erroneous  conclusion  that  they  will  not  there- 
fore repay  the  trouble  of  study.  Our  failures  in  treatment  are  not 
unfrequently  the  result  of  ignorance,  and  a  little  pains  bestowed  on 
ascertaining  the  true  principles  of  diagnosis,  and  acquiring  an  ap- 
titude in  discriminating  the  varieties  which  these  diseases  present, 
will  very  soon  enable  the  student  to  learn  for  himself  what  mode  of 
treatment  is  useful  in  one  form,  useless  or  even  hurtful  in  another. 
It  will  thus  limit  the  choice  of  his  remedies  to  a  few  that  may  do  real 
good,  in  place  of  his  ringing  the  changes  on  a  variety  of  impotent 
drugs,  to  be  at  last  relieved  of  a  tedious  and  unmanageable  case  only 
by  some  accidental  change  in  the  constitution  of  the  patient  which 
at  once  dissipates  the  local  disorder. 

On  a  superficial  view  nothing  should  be  simpler  than  the  dia- 
gnosis of  skin  diseases.  If  a  man  but  use  his  eyes  aright,  it  maybe 
said,  he  ought  to  be  able  at  once  to  distinguish  them :  here  is  surely 
an  instance  in  which  the  symptom  is  pathognomonic  of  the  disease. 
In  this,  I  believe,  consists  the  great  difficulty,  and  this  short-sighted 
reasoning  is  one  of  the  chief  causes  of  the  ignorance  that  prevails. 
If  the  scope  and  intention  of  the  preceding  pages  have  been  made 
at  all  intelligible,  no  argument  is  needed  to  prove  that  skin  diseases 
do  not  in  this  respect  differ  from  others;  they  are  by  no  means  iso- 
lated facts  in  the  economy;  and  while  we  must  acknowledge  the 
faulty  action  in  one  tissue,  we  must  not  ignore  it  elsewhere.  The 
evidence  of  the  constitutional  fault  is,  however,  not  always  manifest, 
and  when  present,  its  language  is  not  always  the  same.     The  symp- 


392  DISEASES    OF   THE    SKIN. 

toms  which  were  enumerated  in  the  early  part  of  our  inquiry,  as  in- 
dicating the  general  condition  of  the  patient,  have  to  be  reviewed; 
but  though  we  find  some  preponderating  more  than  others  in  par- 
ticular classes  of  skin  diseases,  there  are  none  which  may  be  fairly 
classed  as  diagnostic  of  any  individual  disorder.  AVe  are  thus  forced 
to  take  up  the  two  subjects  separately,  and  frame  our  diagnosis  of 
the  cutaneous  affection,  independently  of  the  more  general  derange- 
ment of  which  it,  is  chiefly  a  symptom;  and  this  limitation  prevents 
our  being  able  to  correct  the  opinions  based  upon  one  set  of  observa- 
tions by  that  derived  from  the  other. 

One  rule  may  be  given  at  the  outset  as  applicable  to  all  cases,  and 
especially  to  those  about  which  there  is  doubt,  that  the  distinguish- 
ing characters  are  most  readily  traced  in  the  commencement  of  the 
disease,  and  the  student  should  make  it  his  business  always  to  see 
the  most  recent  spots  of  the  eruption.  This  is  in  fact  the  history 
of  the  case,  which  is  often  written  more  correctly  in  the  different 
patches  on  the  skin  of  the  patient  than  it  is  ever  detailed  in  the  most 
accurate  case  book.  Next  in  value  to  seeing  the  eruption  at  its 
earliest  stage  is  a  good  account  of  it  from  the  patient  himself;  and 
in  this  we  have  only  to  guard  against  asking  leading  questions,  where 
interrogation  is  so  necessary  to  elicit  the  facts  at  all. 

In  certain  forms,  concomitant  fever  may  or  may  not  exist,  and  in 
such  it  is  essential  to  mark  its  presence  or  absence;  but  this  rather 
with  reference  to  treatment  than  to  diagnosis,  for  we  do  not  regard 
those  as  cutaneous  diseases  of  which  fever  is  an  essential  element: 
we  deal  with  it  simply  as  one  of  the  constitutional  states  which  must 
be  considered  in  its  casual  relation  to  the  eruption,  of  whatever 
nature,  which  is  present. 

§  1.  Erythema —  Urticaria — Roseola. — In  subdividing  the  subject 
of  this  chapter,  it  will  be  most  convenient  to  consider  those  forms, 
first,  in  which  the  epidermis  is  not  altered;  the  skin  is  red,  perhaps 
elevated  and  tender,  but  its  surface  is  unbroken. 

The  eruption  of  erythema  consists  of  a  uniform  redness,  with 
puffiness  of  the  skin,  distributed  in  distinct  patches  of  some  size:  it 
is  accompanied  by  little  constitutional  disturbance.  When  fever  is 
present,  we  suspect  either  that  the  disorder  is  not  erythema,  or  that 
the  febrile  symptoms  have  some  other  cause.  The  skin,  though  some- 
what elevated,  has  not  the  hardness  of  erysipelas:  after  the  first 
day  or  two  the  colour  becomes  bluish  or  livid,  and  this  to  an  in- 
experienced eye  might  simulate  the  dusky  redness  of  diffuse  cellular 
inflammation ;  but  the  heat  and  the  tension  are  absent,  as  well  as 
the  constitutional  irritation. 

One  variety  only  deserves  mention  on  account  of  its  distinguish- 
ing characters — erythema  nodosum:  most  commonly  seen  on  the 
anterior  aspect  of  the  leg,  it  appears  in  distinct  rounded  patches, 
which  are  considerably  elevated,  and  very  tender. 


LICHEN    AND    PRURIGO.  393 

This  variety  is  believed  by  some  to  be  a  form  of  rheumatism  :  as  the  attack  sub- 
sides the  patches  become  soft,  and  present  something  very  like  a  sense  of  fluctua- 
tion, but  they  do  not  suppurate.  In  the  broadest  sense,  any  red  patch  on  the  sur- 
face of  the  body  which  is  not  caused  by  erysipelas  might  be  called  erythema. 
Writers  on  skin  diseases  often  enumerate  all  such  cases,  and  describe  the  various 
causes  which  might  give  rise  to  the  appearance:  it  seems  better  to  restrict  the 
name  to  those  instances  in  which  the  redness  is  produced  by  something  more  than 
mere  irritation  of  the  skin,  and  in  which  it  is  not  sympathetic  only,  as  when  a  red 
patch  is  seen  over  a  joint  affected  with  acute  rheumatism.  But  an  erythematous 
blush  so  often  points  out  the  situation  of  grave  and  serious  mischief  that  whenever 
fever  is  present  it  becomes  our  duty  to  study  the  case  very  carefully,  in  order  to 
discover  the  deeper-seated  lesion,  of  which  none  are  more  important  than  cellular 
inflammation  and  secondary  suppuration. 

Urticaria,  "nettle  rash,"  by  its  very  name,  gives  an  idea  of  its 
general  form;  but  while  the  sting  of  the  nettle  raises  a  white  wheal 
on  a  sensitive  skin,  the  colour  of  the  patches  of  urticaria  is  generally 
redder  than  that  of  the  surrounding  surface.  This  is  often  perhaps 
the  consequence  of  its  duration,  just  as  the  mark  of  a  lash  is  first 
paler,  and  then  redder  than  the  rest  of  the  skin ;  sometimes  the 
patches  are  deep-coloured  from  the  first,  and  when  they  continue 
for  any  length  of  time,  they  tend  to  become  purple  or  bluish.  The 
eruption  is  attended  with  tingling  or  itching:  its  progress  is  some- 
times very  rapid,  lasting  not  more  than  one  or  two  days  if  it  be  the 
result  of  something  taken  as  food  or  medicine;  in  other  instances 
it  continues  for  a  week  or  two,  and  occasionally  in  its  chronic  form 
it  mav  exist  in  more  or  less  distinctness  for  weeks  or  months. 

It  is  distinguished  from  all  other  cutaneous  affections,  which  are 
similarly  distributed,  by  its  patches  being  perfectly  smooth;  there 
is  neither  oozing  nor  desquamation  of  the  surface;  it  can  hardly  be 
confounded  with  erythema  nodosum,  which  forms  in  much  larger 
patches  with  less  defined  border. 

I  am  inclined  to  regard  roseola  as  a  sort  of  spurious  exanthem; 
it  is  to  be  seen  when  measles  are  about,  as  well  as  when  scarlatina 
prevails,  but  without  the  coryza  of  the  one  or  the  sore-throat  of  the 
other.  It  resembles  those  diseases  in  attacking  young  persons  and 
presenting  febrile  symptoms,  though  of  a  very  slight  and  evanescent 
character.  It  maybe  best  described  negatively:  the  patches  are 
not  small  and  semilunar  as  in  measles,  nor  are  they  punctuate  and 
close-set  as  in  scarlatina,  and  the  whole  surface  is  never  involved, 
as  is  sometimes  the  case  in  the  eruptive  fevers;  though  roundish  in 
form,  the  borders  are  not  defined,  nor  the  surface  elevated  as  in  ery- 
thema or  urticaria,  and  there  is  no  attendant  irritation  or  itching. 

§  2.  Lichen  and  Prurigo. — In  this  subdivision  there  is  also  no 
necessary  breach  of  surface;  the  cuticle  is  elevated  in  small  distinct 
points,  without  any  secretion,  and  the  desquamation  is  accidental: 
the  eruption  is  of  the  form  designated  as  papular.  It  seldom  hap- 
pens, however,  that  it  is  seen  exactly  in  this  condition,  because 
there  is  always  itching,  and  the  top  of  the  papule  becomes  abraded, 
leaving  a  red  spot  or  a  small  crust  of  coagulated  blood.     The  dia- 


S04  DISEASES    OF    TIIE    SKIN. 

gnosis  is  not  difficult  if  these  circumstances  be  considered;  and 
even  when,  as  in  the  severer  form  of  lichen  ajrius,  suppuration 
exists,  ca rcfal  inquiry  will  disclose  that  such  a  condition  has  only 
arisen  in  consequence  of  the  long  continuance  of  the  disorder  in  a 
cachectic  individual,  and  was  not  the  form  in  which  it  first  appeared: 
other  portions  of  the  eruption  may  also  be  discovered  in  which  the 
papular  character  is  manifest. 

The  distinction  between  ordinary  lichen  and  prurigo  is  really  more  a  question  of 
names  than  of  things.  It  may  be  observed  that  lichen  is  more  generally  grouped 
in  patches,  prurigo  is  more  diffuse;  the  itching  of  the  former  is  comparatively 
alight,  that  of  the  latter  intense  and  intolerable;  as  a  necessary  consequence  the 
skin  is  abraded  by  the  nails,  and  a  case  of  prurigo  is  always  marked  by  scratches 
and  bloody  points.  The  cases  in  which  the  disease  runs  an  acute  course,  and 
those  in  which  it  presents  any  tendency  to  ulceration  and  suppuration,  are  both 
commonly  referred  to  lichen,  the  more  ordinary  chronic  papular  eruption  is  usually 
called  prurigo. 

One  or  two  varieties  must  be  mentioned,  not  so  much  on  account  of  their  indi- 
vidual importance,  as  that  their  diagnosis  is  obscure.  The  lichen  cireumscriptus 
assumes  a  very  complete  circular  form,  which  in  common  parlance  brings  it  under 
the  general  classification  of  "ringworm,"  a  name  which  includes  diseases  by  no 
means  related  to  each  other:  to  the  student  this  appearance  is  apt  to  suggest  the  idea 
of  lepra  or  even  herpes.  With  the  latter  it  ought  not  to  be  confounded,  because 
e  is  no  secretion,  no  vesication,  no  crust:  from  the  former  it  is  distinguished  by 
the  circumstance  that  desquamation  is  the  principal  feature  of  the  one,  is  only  an 
accidental  occurrence  in  the  other.  In  lepra  lar^e  white  scales  surround  a  portion 
of  skin  which  scarcely  differs  from  that  of  health,  in  lichen  cireumscriptus  the 
whole  surface  is  rough,  even  though  the  edge  be  more  elevated  than  the  centre; 
the  desquamation  of  the  cuticle  occurs  as  small  fine  scales,  and  is  quite  a  subor- 
dinate phenomenon:  the  patches  of  lepra  are  large  or  numerous,  of  lichen  smaller 
and  solitary. 

The  same  affection  occurring  in  the  scalp  gives  rise  to  what  is  very  often  called 
porrigo  decalvans,  a  name  as  undefined  as  the  vulgar  epithet  of  ring-worm.  It  is 
marked  by  the  hair  falling  off  in  a  circular  patch,  the  surface  being  roughened 
and  covered  with  minute  scales;  there  is  no  vesication,  suppuration,  or  ulceration. 
In  this  respect  it  differs  from  most  other  diseases  which  produce  loss  of  hair,  when 
there  has  been  some  previous  severe  affection  of  the  scalp,  and  the  patch  of  bald- 
ness only  comes  to  be  remarked  when  the  skin  has  again  recovered  its  natural  con- 
dition ;  in  that  form  of  porrigo  to  which  the  name  decalvans  should  be  limited, 
the  hair  falls  off  in  consequence  of  disease  of  the  bulb  apparently  caused  by  a  pa- 
rasitic fungus,  the  skin  being  left  perfectly  smooth  and  free  from  scurf. 

In  the  lichen  strophulus  of  childhood  the  papular  character  of  the  eruption  is 
least  defined.  It  consists  of  distinct  spots  scattered  all  over  the  body,  but  espe- 
cially the  arms  and  legs,  which  are  white  and  elevated,  and  have  a  semi-trans- 
parent appearance,  almost  exactly  analogous  to  a  vesicle :  it  is  less  to  be  dis- 
tinguished by  its  aspect  than  by  the  fact,  that,  with  the  exception  of  varicelloid 
eruptions,  there  is  no  disease  in  which  solitary  vesicles  are  uniformly  distributed: 
they  are  either  grouped  together,  or  they  affect  certain  localities  more  than  others. 

The  prurigo pudendi  again  deserves  notice  from  the  occasional  absence  of  all 
eruptive  character  together.  It  is  no  doubt  often  caused  by  want  of  cleanliness, 
by  the  presence  of  irritating  secretions,  of  slight  eczema,  or  some  form  of  parasite 
about  the  roots  of  the  hair;  but  undoubtedly  pruritus  does  exist  without  any  of 
these  causes,  and  it  must  then  be  regarded  as  sympathetic  of  internal  irritation  of 
the  uterus,  the  bladder  or  the  rectum.  The  same  remarks  apply  even  more  con- 
stantly to  prurigo  podieis,  which  is  constantly  associated  with  internal  haemor- 
rhoids and  ascarides.  If  these  be  regarded  as  instances  of  a  sympathetic  or  neu- 
ralgic character,  it  may  be  doubted  whether,  in  a  great  number  of  cases,  the  same 
explanation  might  not  be  given,  the  appearance  of  eruption  being  really  the  effect 
of  scratching:  this  is  especially  true  of  that  form  which  is  associated  with  a  gouty 
habit. 


SQUAMOUS    DISEASES.  395 

Lichen  and  prurigo  are  generally  distributed  on  the  outward  as- 
pect of  the  limbs,  and  avoid  the  flexures  of  the  joints.  In  this 
respect  they  especially  differ  from  scabies,  with  which,  notwith- 
standing the  great  dissimilarity  of  the  original  lesion,  they  are 
sometimes  confounded,  because  of  their  intolerable  itching,  and  the 
change  which  is  produced  in  their  appearance  by  constant  scratch- 
ing. 

§  3.  Squamous  Diseases. — The  next  class  is  one  in  which  the 
cuticle  is  materially  altered  in  its  form  and  character.  It  does  not 
desquamate  accidentally  in  consequence  of  a  casual  interruption  to 
the  secretion,  as  in  scarlatina  or  erysipelas;  nor  does  the  presence 
of  a  papule,  as  in  the  last  class,  cause  the  premature  death,  so  to 
speak,  of  the  small  portion  of  cuticle  which  covers  it;  but  the  epi- 
dermis is  secreted  in  some  abnormal  manner  which  leads  to  its 
agglomeration  into  scales  of  some  size.  In  one  form,  ichthyosis, 
they  remain  attached,  and  acquire  a  horny  hardness;  in  the  others, 
lepra  and  psoriasis,  they  gradually  become  disconnected  with  the 
cutis,  and  fall  off. 

There  is  no  disease  which  can  be  confounded  with  ichthyosis. 
Certain  trades  produce  an  unusual  thickness,  hardness,  and  dry- 
ness of  the  cuticle,  which  may,  in  some  degree,  simulate  it;  but 
when  occurring  in  parts  of  the  skin  not  so  exposed  there  cannot 
well  be  any  mistake.  Sometimes,  indeed,  on  recovery  from  chronic 
eczema,  the  skin  may  for  a  time  be  hard  and  dry,  but  the  history  of 
the  case  sufficiently  distinguishes  the  two  disorders:  ichthyosis  is  a 
congenital  malady. 

There  is  no  practical  advantage  in  separating  lepra  from  jisori- 
asis.  Some  cases  are  certainly  more  obstinate  than  others;  and  in 
the  text-books  of  skin  diseases  several  varieties  are  recorded  which 
depend  in  great  measure  on  the  duration  and  intensity  of  the  dis- 
ease: its  essence  is  the  same,  and  in  diagnosis  it  matters  little  which 
name  is  assigned.  As  a  general  rule,  those  cases  in  which  healthy 
skin  is  surrounded  by  squamous  portions,  especially  in  an  annular 
form,  are  called  lepra,  while  those  in  which  numerous  small  spots, 
or  single  larger  patches,  are  wholly  covered  by  scales  are  called 
psoriasis ;  the  crusts,  too,  in  the  former  are  more  adherent,  and 
consequently  larger  and  whiter  than  in  the  latter. 

The  greatest  difficulty  in  recognising  the  character  of  the  eruption  is  experienced 
when  the  scales  have  been  removed  by  a  warm  bath ;  the  fresh  cuticle  underneath 
them  presents  a  red  shining  aspect,  which  may  for  a  moment  be  mistaken  for 
chronic  eczema.  When  it  begins  by  a  solitary  patch  it  may  be  difficult  to  dis- 
tinguish it  from  lichen  circumscriptus,  especially  on  the  hand  or  face,  where  con- 
stant washing  removes  the  scales  as  soon  as  formed.  The  distinction  rests  on  the 
principle  already  enunciated,  that  in  the  squamous  diseases  the  cuticle  is  secreted 
in  an  unnatural  condition,  and  consequently  where  the  scale  has  been  removed 
the  skin  looks  red,  and  smooth,  and  shining,  whereas  in  lichen  the  detachment  of 
the  cuticle  is  only  caused  by  its  nutrition  being  interfered  with  from  the  existence 
of  papules,  which  give  a  certain  degree  of  irregularity  to  the  surface. 

Like  the  previous  class  these  diseases  especially  affect  the  outer  sides  of  the 


396  DISEASES    OF    THE    SKIN. 

limbs,  and  avoid  tl,.-  flexures  of  the  joints.  They  are  not  necessarily  attended 
with  itching,  bnt  if  once  irritated  the  itching  sometimes  becomes  very  intense. 
'1'i,,..  entially  chronic  in  character,  and  the  history  only  shows  that  there 

has  b  n  a  rough  patch  observed  somewhi  re  or  other  which  has  not  received  any 
attention  till  it  has  attained  some  size,  or  till  the  same  eruption  has  appeared  else- 
where. 

Pityriasis  used  to  be  classed  as  a  squamous  disease;  perhaps  one 
of  its  varieties,  pityriasis  capitis,  marked  by  a  constant  excessive 
desquamation  of  the  cuticle  over  the  scalp,  which  falls  as  white 
powder  when  the  hair  is  brushed,  ought  still  to  be  considered:  it  is 
nothing  more  than  an  excess  of  natural  secretion,  and  can  scarcely 
be  classed  among  diseases  of  the  skin.  Pityriasis  versicolor  is  now 
referred  to  the  parasitic  growths ;  its  most  prominent  feature  is  the 
change  of  colour  over  the  parts  affected. 

§  4.  Vesicular  Eruptions.— In  this  class  we  meet  with  cases  of 
very  varying  intensity,  which,  according  to  the  stage  at  which  they 
are  seen,  may  resemble  squamous  or  pustular  eruptions.  The  rea- 
son for  grouping  them  together  is,  that  the  primary  element  in  all 
is  a  vesicle,  and  the  practical  utility  of  such  a  classification  consists 
in  this,  that  when  such  an  origin  can  be  traced,  there  is  no  diffi- 
culty in  deciding  to  which  of  the  vesicular  diseases  any  case  ought 
to  be  referred.  °  The  first  inquiry,  therefore,  will  be  how  long  the 
disease  has  lasted,  and  how  it  commenced;  and  then  search  must 
be  made  for  a  vesicle  in  the  early  stage.  If  the  first  appearance 
of  the  disorder  cannot  be  traced,  we  have  to  remember  that  the 
serum  must  either  continue  to  ooze  away,  keeping  the  part  con- 
stantly moist,  or  harden  into  a  gum-like  crust,  or  that  it  may  dry 
up  altogether,  leaving  small,  round,  dry  scales,  as  the  only  remains 
of  the  vesicle;  but,  on  the  other  hand,  by  exposure,  the  cutis  may 
be  irritated,  and  produce  a  purulent  secretion,  which  forms  crusts 
like  those  of  the  pustular  eruptions.  The  last  two  alone  can  give 
rise  to  any  difficulty  in  diagnosis,  and  they  belong  to  one  form  of 
eruption — viz.,  eczema. 

In  this  variety  a  number  of  vesicles  are  always  found  together, 
coalescing  and  forming  a  patch  of  varying  size.  It  is  distinguished 
from  the'other  vesicular  eruptions  by  their  neither  being  disposed 
in  regular  groups,  nor  occurring  singly.  In  its  simple  form  the 
vesicles  either  constantly  form  on  an  uninflaraed  surface,  and  gradu- 
ally disappear,  or  the  skin  continues  red  and  moist  after  they  have 
burst;  in  the  former,  the  appearance  of  flesh  vesicles  prevents  our 
referring  the  shrivelled  and  dry  ones  to  any  scaly  eruption ;  in  the 
latter,  the  moistened  surface  prevents  its  being  mistaken  for  ery- 
thema, or  erysipelas,  which  is  the  name  commonly  applied  to  it  by 

patients. 

Occasionally  the  reddened  skin  is  dry,  and  covered  with  small 
scales:  that  this  is  not  psoriasis  is  proved  by  the  circumstances, 
that  the  skin  is  evenly  inflamed  all  over,  and  that  the  scales  are 
rfbt  aggregated  in  patches  which  run  into  each  other.     As  a  conse- 


VESICULAR   ERUPTIONS.  397 

quence  of  the  inflammation,  the  skin  is  generally  cracked  and  some- 
times bleeds,  and  this  never  happens  with  psoriasis  unless  the  scales 
be  very  thick  and  adherent,  when  the  diagnosis  cannot  be  difficult. 
This  form  of  eczema  is  best  seen  in  what  is  called  "grocer's  itch," 
or  on  the  hands  of  washerwomen. 

"When  the  oozing  from  the  surface,  in  place  of  continuing  as  a 
thin  serosity,  becomes  purulent  and  hardens  into  crusts,  the  name 
eczema  impetiyinodes  has  been  employed.  It  is  quite  unnecessary 
to  distinguish  this  from  real  impetigo,  foil  the  diseases  are  closely 
analogous,  except  when  the  borders  of  the  eruption  are  red  and  in- 
flamed, and  the  eczema  is  spreading;  if  there  be  only  a  chronic 
purulent  discharge,  the  name  given  is  quite  immaterial. 

The  great  characteristic  of  herpes  is,  that  the  vesicles  are  dis- 
tributed in  groups  or  clusters:  they  are  also  larger  than  those  of 
eczema,  and  do  not  so  readily  fuse  together.  On  their  disruption 
the  secretion  almost  always  forms  a  gum-like  scab;  their  duration 
is  commonly  short. 

Among  its  more  constant  forms  we  find  the  following:  Herpes  labialis, — occur- 
ring in  one  or  two  patches  on  the  lips,  sometimes  on  the  nose,  and  more  rarely 
about  the  eyelids;  in  common  parlance  described  as  the  effect  of  "a  cold,"  and 
evidently  associated  with  irritation  of  the  mucous  membrane.  Herpes  cireiinatus, 
— one  of  the  "ring-worms"'  in  which  the  clusters  assume  an  annular  form;  the 
vesication  and  the  scab  alike  distinguish  it  from  lichen  circumscriptus  and  from 
lepra;  there  can  be  no  excuse  for  a  mistake,  except  when  the  eruption  is  disap- 
pearing. Herpes  zoster  is  only  remarkable  for  its  situation,  and  the  extent  to  which 
it  may  extend,  encircling  as  it  does  the  one-half  of  the  trunk,  and  though  generally 
bounded  in  a  remarkable  manner  by  the  mesian  line  before  or  behind,  jet  some- 
times passing  beyond.  Herpes  preputialis  is  worthy  of  notice  because  it  has  been 
sometimes  mistaken  for  chancre;  it  has  no  peculiar  characters  to  distinguish  it 
from  any  other  form  of  herpes;  it  is  perfectly  different  from  any  syphilitic  affection. 

Patches  of  herpes  wherever  occurring,  usually  known  as  "shin- 
gles," except  in  the  few  instances  enumerated,  are  so  exactly  like 
the  eruption  on  the  lip,  which  is  familiarly  known  to  every  one,  that 
description  is  unnecessary.  It  is  often  preceded  by  considerable 
local  irritation,  and  a  sort  of  cutaneous  neuralgia  very  frequently 
remains  after  it  has  died  away. 

Scabies  should  not,  perhaps,  in  a  scientific  work  be  classed  as  a 
vesicular  disease,  because  the  vesicle  is  really  an  accident,  and  may 
be  replaced  by  a  pustule.  But  for  purposes  of  diagnosis  it  is  well 
to  retain  it  in  its  present  place,  because  whereas  lichen,  prurigo 
and  the  scaly  diseases  all  have  their  chief  site  on  the  outer  sides 
of  the  limbs  and  back  of  the  trunk,  the  vesicular  eruptions  gene- 
rally, and  scabies  in  particular,  select  the  inner  aspects  of  the  limbs 
and  the  flexures  of  the  joints.  The  acarus,  which  is  the  essence  of 
the  disease,  does  not  inhabit  the  vesicle,  but  grooves  out  a  curved 
channel  for  itself,  which  may  be  generally  seen  as  a  black  line  like 
the  letter  S:  but  its  presence  always  determines  the  eruption  of 
solitary  vesicles,  which  may  in  course  of  time  become  pustules;  and 
these  are  sure  to  be  found  at  the  flexure  of  the  wrist  or  between 


DISEASES    OF   THE    SKIN. 

tin'  fingers,  and  along  the  inner  sale  of  the  arm,  wherever  else  they 
may  be.  One  vesicle  with  a  distinct  groove  from  it  in  such  a  situa- 
tion, is  enough  for  diagnosis;  any  amount  of  itching  without  these 
is  of  no  value:  prurigo  causes  quite  as  much  itching,  and  pus- 
tular, or  even  quasi-vesicular  eruptions,  occur  very  frequently  among 
children  of  the  lower  classes  which  closely  resemble  scabies,  and  can 
only  be  pronounced  not  to  be  so  by  observing  this  remarkable  pre- 
dilection for  locality  and  the  constant  presence  of  the  groove  Avhen 
the  parasite  is  really  present. 

§  5.  Pustular  Eruptions. — A  fully-developed  pustule  is  quite  un- 
like any  thing  else,  but  just  as  at  certain  stages  of  the  vesicular 
eruptions  the  secretion  is  not  serum,  so  in  the  pustular  the  secretion 
is  at  first  not  true  pus,  and,  after  the  pustule  has  burst  and  dis- 
charged, the  crust  may  not  be  quite  characteristic.  In  impetigo 
this  difficulty  is  most  likely  to  be  met  with,  because  its  characters 
vary  as  the  disease  is  spread  over  a  large  surface  in  solitary  pus- 
tules, called  impetigo  sparsa,  or  is  limited  to  distinct  patches,  when 
the  name  figurata  is  applied  to  it.  In  the  former  the  single  pus- 
tules have  at  first  much  the  appearance  of  vesicles,  but  they  very 
soon  lose  their  transparency:  among  vesicular  diseases  we  have 
found  no  such  example  except  scabies;  and  therefore,  when  a  case 
of  this  kind  is  met  with,  the  question  cannot  be,  is  it  eczema  which 
exists  only  in  patches,  or  herpes  which  forms  small  and  well-defined 
groups,  but  whether  it  be  scabies  or  impetigo:  the  answer  is  only 
to  be  obtained  from  the  diagnosis  of  scabies.  "When,  again,  the 
eruption  occurs  in  patches  it  is  more  liable  to  be  mistaken  for  her- 
pes: but  the  course  of  the  two  diseases  is  quite  different;  the  one 
commences  suddenly,  and  is  preceded  by  irritation,  the  other  is 
gradual,  and  its  beginning  is  unobserved;  the  one  terminates  in  a 
few  days,  the  other  lingers  on  for  weeks  or  months. 

The  common  history  of  impetigo  is  that,  after  some  degree  of 
redness  and  tumefaction  of  the  skin,  one  or  more  distinct  pustules 
slowly  make  their  appearance,  the  irritation  which  accompanies 
them  being  so  slight  as  to  escape  observation  in  most  instances, 
and  the  eruption  itself  receiving  little  attention.  The  matter  con- 
tained in  them  very  soon  becomes  decidedly  purulent  and  forms  a 
firm  scab;  but  before  those  first  observed  have  had  time  to  dry  up, 
others  appear  in  succession,  which  are  either  scattered  and  distinct, 
or  in  close  proximity  to  the  former.  .  It  is  scarcely  possible  to  say  in 
the  first  instance  which  of  the  two  varieties  is  likely  to  be  developed. 

When  the  disease  has  already  lasted  some  time,  and  a  thick  crust  has  formed, 
it  matters  little  whether  it  be  called  eczema  impetiginodes  or  impetigo, — -herpes  it 
cannot  be;  for  the  only  question  worth  considering  is,  whether  there  be  any  ap- 
pearance of  redness  or  tendency  to  spread  about  its  margin.  The  crusts  of  dry 
pus,  when  solitary  and  rather  large,  are  very  like  those  of  the  next  subdivision, 
ecthyma;  when  in  clusters,  or  covering  a  large  surface  of  the  scalp,  they  can  only 
be  mistaken  for  favus.  The  scalp  and  neck,  and  face,  are  the  chief  sites  of  im- 
ignrata,  which  is  more  rarely  seen  on  the  limbs:  impetigo  sparsa  occurs 
chiefly  on  the  back  and  arms,  and  less  frequently  on  the  legs. 


PEMPHIGUS    AND    RUPIA.  399 

In  Ecthyma  the  pustules  are  large  and  solitary,  although  very 
often  a  number  are  found  together  on  one  limb,  and  none  else- 
where, showing  thus  a  tendency  to  aggregation.  The  great  dis- 
tinction between  it  and  impetigo,  independently  of  the  difference  of 
size  in  the  pustules,  seems  to  be  that  the  cutaneous  texture  is  more 
deeply  affected:  in  the  one  there  is  an  abraded  surface  which  se- 
cretes pus,  in  the  other  there  is  a  nearer  approach  to  an  ulcer  under 
the  dry  crust  with  which  it  is  covered.  This  brings  it  into  close  rela- 
tion to  rupia,  which  is  only  distinguished  by  the  ulceration  being 
more  unequivocal,  the  scab  larger  and  more  adhering:  in  rupia, 
too,  there  is  no  tendency  to  aggregation,  the  scabs  are  few  and 
solitary. 

Ecthyma  is  seldom  found  in  the  chronic  form :  it  is  easily  distinguished  from 
boils  or  carbuncle  by  the  circumstance  that  it  is  quite  superficial,  and  there  is  con- 
sequently no  surrounding  elevation  of  hard  and  tumid  skin,  as  when  the  suppura- 
tion proceeds  from  the  deeper  textures.  Nothing  has  been  said  of  the  syphilitic 
eruptions,  because  they  must  be  taken  by  themselves,  but  it  is  worth  noticing  here 
that  when  there  is  much  approach  to  ulceration  this  disease  comes  nearer  in  ap- 
pearance to  one  of  the  common  forms  of  secondary  eruption  than  any  we  have  yet 
had  to  refer  to. 

Acne  and  Sycosis  are  names  applied  to  suppuration  of  the  follicles. 
The  latter  confined  to  that  which  appears  at  the  roots  of  the  hair 
in  the  beard,  the  former  including  all  other  cases.  In  this  sense, 
every  common  pimple  maybe  called  acne;  but. the  name  is  reserved 
for  cases  in  which  there  are  so  many  as  to  show  a  general  tendency 
to  this  kind  of  suppuration.  Although  the  course  of  each  individual 
pimple  be  not  very  prolonged,  yet  the  progress  of  the  disease  is 
slow:  not  unfrequently  this  tardiness  is  shown  in  persistent  redness 
after  the  actual  suppuration  is  at  an  end,  and  its  continued  recur- 
rence in  the  same  follicles.  When  such  a  blotchy  redness  alone 
remains,  and  no  pustule  is  to  be  seen,  a  learner  may  be  at  a  loss  to 
what  class  he  ought  to  refer  the  case;  its  rugged  surface  renders  it 
unlike  eczema,  and  the  absence  of  crust  shows  that  it  is  not  im- 
petigo; its  redness  and  its  position,  only  on  the  face  or  back  of  the 
neck,  prevent  its  being  confounded  with  lichen  or  psoriasis:  it  is 
most  apt  to  be  taken  for  tubercle-of  the  skin. 

Sycosis  much  more  nearly  resembles  impetigo:  crusts  generally 
form,  and  are  very  obstinate  and  adherent:  but  it  is  to  be  observed 
that  the  skin  is  elevated  round  the  crust,  which  is  just  what  we 
should  expect  from  the  circumstance  that  the  suppuration  proceeds 
from  a  follicle  deeply-seated  in  the  cutis,  and  not  from  its  surface. 

Favus,  which  has  been  classed  among  pustules,  we  shall  refer  to 
its  true  place  as  a  parasitic  growth. 

§  6.  Pemphigus  orPompholyx  and  Rupia. — These  two  disorders, 
although  very  different  in  their  history  and  causes,  may  conveniently 
be  classed  together,  because  they  are  characterized  by  the  existence 
of  bullae  (literally  bubbles.)     In  pemphigus  the  contents  of   the 


400  DISEASES   OF   THE    SKIN. 

bulla  arc  always  serous,  in  rupia  puriform  ;  and  tlicy  thus  correspond 
in  Borne  measure  to  the  division  of  the  smaller  eruptions  into  vesicular 
and  pustular.  In  connexion  with  this  there  is  a  similarity  in  history, 
the  one  appearing  more  frequently  in  an  acute  form,  the  other 
being  always  chronic;  there  is  also  a  chronic  pemphigus,  to  which 
name  pompholyz  is  given,  to  complete  the  analogy  with  chronic 
eczema. 

Whether  this  disease  be  of  shorter  or  longer  duration  there  i3 
always  redness  of  the  skin,  the  cuticle  rising  in  separate  blisters, 
generally  rounded  and  prominent,  and  filled  with  serum;  the  dura- 
tion of  each  blister  is  not  long,  but  great  difference  is  observed  in 
the  rapidity  with  which  the  subsequent  healing  process  goes  on. 
There  can  be  no  question  as  to  whether  it  be  a  vesicular  eruption, 
because  of  the  immense  difference  in  size;  indeed,  the  only  disease  in 
which  similar  blisters  are  ever  seen  is  erysipelas;  and  for  this  it 
cannot  be  taken. 

In  the  sequel  the  appearance  of  the  skin  depends  much  on  the  rapidity  of  the 
healing  process;  and  when  fresh  bullae  have  ceased  to  appear,  or  the  morbid  ac- 
tion is  for  a  time  suspended,  there  may  be  considerable  doubt  as  to  the  true  nature 
of  the  disorder.  The  skin  may  be  merely  morbidly  red  in  patches,  or  it  may  be 
covered  with  roundish  spots  over  which  the  cuticle  has  been  r<  moved,  and  new 
epidermis  is  funning;  or  again,  these  spots  may  be  covered  with  a  sero-purulent 
discharge,  which  in  some  is  converted  into  a  thin  crust:  in  such  instances  the  his- 
tory of  the  case  will  best  explain  the  meaning  of  what  is  seen. 

Rupia,  although  it  be  said  to  commence  as  pemphigus  does,  in  a 
bulla  of  some  size,  presents  but  fewr  analogies  to  it.  It  is  far  more 
nearly  related  to  ecthyma;  it  is  not  a  blister  full  of  clear  liquid, 
but  a  very  large  pustule,  which  does  not  come  from  beneath  the  skin 
like  a  boil,  but  yet  goes  deeper  into  its  texture  than  the  mere  pus- 
tular eruptions,  leaving  an  ulcerated  surface,  of  considerable  depth, 
covered  by  a  thick  crust.  This,  its  ulterior  stage,  is  the  character- 
istic one  of  rupia.  It  has  been  compared  to  a  limpet-shell,  and  the 
resemblance  is  in  some  instances  not  far-fetched.  In  its  earlier 
stage  the  spots  are  few  and  large,  and  there  is  not  much  redness 
around;  they  contain  unmixed  pus,  not  bloody  or  sanious  matter: 
but  it  is  only  when  there  remain  .solitary  spots  of  ulceration,  of  a 
circular  form,  covered  with  a  thick  crust,  around  which  the  skin  is 
moderately  elevated,  that  the  disease  deserves  the  name  of  rupia ; 
and  in  whatever  way  it  have  commenced,  whether  like  ecthyma  or 
even  impetigo,  it  is  now  rupia;  and  the  name  is  of  importance,  be- 
cause it  at  once  points  to  a  condition  of  system. 

We  shall  have  to  refer  to  this  form  of  disease  when  speaking  of  syphilitic  affec- 
tions, and  it  is  of  vast  importance  to  be  able  to  say  whether  rupia  be  or  be  not 
specific.  But  there  is  one  mistake  which  I  have  seen  made  by  persons  who  form 
diagnosis  from  pathognomonic  signs.  A  limpet-shell  crust  is  to  them  the 
Bign  of  rupia,  and  when  the  desquamating  crust  of  psoriasis  assumes  this  form,  the 
one  is  mistaken  for  the  other.  It  is  surely  needless  to  say  that  the  shape  is  only 
accidental,  the  history  and  the  condition  of  skin  are  perfectly  distinct,  and  not  less 
so  the  condition  of  system. 


TUBERCLE    OF    THE    SKIN.  401 

§  7.  Vegetable  Parasites. — The  distinction  which  this  name  im- 
plies is  only  of  recent  date;  perhaps  microscopical  researches  may 
yet  extend  the  class,  and  at  all  events  we  may  hope  for  more  de- 
finite knowledge  of  the  relation  of  the  variouaforms  of  parasitic  life 
to  the  eruptions  with  which  they  are  associated;  such  as  in  acne 
and  sycosis. 

The  most  important  of  this  class  is  one  that  has  its  seat  in  the 
hair  follicles — favus,  or  porrigo  favosa.  It  used  to  be  classed 
among  the  pustular  eruptions,  because  it  first  appears  as  a  small 
yellow  spot,  the  sheath  of  the  hah-  filled  with  fungous  growth ;  but 
it  has  no  tendency  to  suppurate.  It  grows  with  great  rapidity,  and 
when  neglected  forms  large,  hard,  dry  crusts,  which  have  a  peculiar 
mouse-like  odour.  It  is  most  liable  to  be  confounded  with  impetigo, 
but  it  requires  only  moderate  care  to  determine  whether  the  crust  be 
hardened  pus  or  an  independent  growth.  The  distinction  is  based 
on  the  presence  or  absence  of  secretion :  be  the  crust  of  impetigo 
never  so  dry,  some  trace  of  purulent  secretion  is  sure  to  be  met 
with  ;  and  if  removed  by  a  poultice,  the  moist,  exuding  surfaces 
cannot  be  mistaken.  Knowing  this  fact,  we  have  no  need  to  par- 
ticularize the  rounded  form,  the  cracked,  broken-looking  surface, 
and  all  the  other  characters  which  older  writers  were  obliged  to 
enumerate.  It  is  met  with  commonly  in  the  head,  but  sometimes 
also  down  the  back  of  the  neck  or  in  front  of  the  ear. 

One  form  of  porrigo  decalvans  belongs  to  this  class.  The  hair 
falls  out  in  a  patch  of  a  circular  form,  leaving  the  skin  of  the  head 
perfectly  smooth:  the  absence  of  cutaneous  eruption  of  any  kind 
proves  that  it  is  connected  simply  with  disease  of  the  hair  and  not 
of  the  skin:  this,  too,  is  found  to  be  a  microscopic  fungus. 

Pityriasis  versicolor  was  long  a  puzzle,  because  it  has  certainly 
something  of  a  squamous  character,  but  in  a  very  subordinate 
degree.  Its  chief  mark  is  a  yellowish-brown  discoloration,  in 
small  circular  patches,  which  sometimes  spread  all  over  the  body. 
There  is  no  vesication,  no  crust;  the  small  scales  of  the  epidermis 
fall  in  larger  quantity  than  in  health,  producing  some  degree  of 
roughness ;  and  the  eruption  is  sometimes  attended  with  much 
itching.  It  is  now  shown  to  be  connected  with  the  growth  of  a 
fungus.  The  varieties  called  rubra  and  nigra  probably  belong  to 
the  same  category :  they  are  described  as  being  very  rare,  and  none 
have  come  under  my  own  observation. 

§  8.  Tubercle  of  the  Shin. — Although  not  a  very  common  malady, 
it  is  necessary  to  point  out  how  it  may  be  distinguished  from  other 
cutaneous  affections  to  which  it  bears  some  resemblance.  It  is  most 
frequently  seen  on  the  face,  and  is  sometimes  limited  to  the  nose  or 
the  ear,  producing  a  most  disagreeable  alteration  of  the  features. 
The  disease  consists  of  smooth,  rounded  eminences,  which  are 
accompanied  by  a  general  puffiness  of  the  adjacent  skin,  and  marked 
by  livid  or  bronze  discoloration.  The  name  is  an  unfortunate  one, 
26 


402  DISEASES    OF   THE    SKIN. 

because  it  is  usually  applied  to  one  particular  development  of  the 
strum oua  diathesis,  with  which  tubercles  of  the  skin  have  nothing 
in  common.  Usually  aggregated  over  a  limited  surface,  the  erup- 
tion does  not  present  ajiy  regular  groups,  except  in  those  rare  forms 
which  have  received  the  names  of  frambossia  and  molluscum,  from 
fancied  resemblances  which  they  present.  In  very  severe  cases  it 
may  implicate  large  tracts  of  skin,  and  then  the  name  "Elephan- 
tiasis of  the  Greeks"  is  applied  to  it:  "Elephantiasis  of  the 
Arabians"  is  a  wholly  different  disease:  French  authors  employ 
this  name  even  in  mild  cases.  It  is  always  accompanied  by  dis- 
order of  the  assimilating  functions,  and  common  belief  assigns  as 
its  frequent  cause  the  improper  use  of  stimulants. 

In  speaking  of  acne  it  was  mentioned  that  at  one  stage  of  its  progress,  when  no 
suppuration  was  going  on,  and  the  skin  presented  a  red  and  rugged  appearance, 
it  was  liable  to  be  confounded  with  tubercle.  Such  a  mistake  is  very  liable  to  be 
made  by  one  who  knows  skin  diseases  only  as  described  in  books,  because  both 
are  equally  found  in  persons  of  dissipated  habits.  Very  little  experience  serves 
to  distinguish  the  smaller  size  and  brighter  colour  of  the  hardened  points  in  acne 
from  the  rounded  knobs  and  livid  colour  of  tubercles:  the  disagreeable  expression 
produced  by  the  tumid  features  of  the  latter  are  very  different  from  the  bloated 
aspect  of  the  drunkard  whose  nose  and  cheeks  are  inflamed  by  an  eruption  of 
acne.  In  addition  to  this,  the  history  if  rightly  inquired  into,  details  the  existence 
of  previous  suppuration  in  the  one  and  its  absence  in  the  other. 

Tubercle  of  the  skin  is  one  of  those  cutaneous  affections  which  have  a  counter- 
part among  the  syphilitic  eruptions:  its  diagnosis,  however,  is,  as  we  shall  find, 
not  diilicult. 

§  9.  Syphilitic  Eruptions. — This  class  of  eruptions  has  no  legi- 
timate place  among  cutaneous  disorders;  they  are  the  mere  expo- 
nents of  a  specific  disease;  but  it  is  necessary  in  a  work  on  dia- 
gnosis to  point  out  their  resemblance  to  some  of  those  which  have 
been  already  enumerated,  and  to  show  how  they  may  be  distinguished 
from  them. 

Their  most  marked  feature  is  the  copper-coloured  tint  of  the 
surrounding  skin  ;  but  this  is  only  another  instance  in  which  persons 
who  trust  to  one  sign,  however  uniform,  are  sure  to  be  occasionally 
mistaken.  Not  only  do  eruptions,  which  are  certainly  not  syphi- 
litic, sometimes  present  a  discoloration  in  healing  which  can  be 
called  by  no  otlw  name,  but  true  syphilitic  eruptions  are  occasion- 
ally free  from  it.  It  is  only  by  studying  the  whole  history  of  the 
affection  that  a  correct  opinion  can  be  formed.  The  first  question 
is  whether  the  characters  of  the  eruption  correspond  exactly  to 
those  belonging  to  any  of  the  classes  of  the  diseases  already  enume- 
rated, because  an  individual  may  have  had  primary  syphilis,  and 
the  system  may  still  not  have  become  infected.  If  it  present  any 
peculiarities,  and  especially  if  marked  by  the  coppery  tint,  the  next 
point  is  to  inquire  into  the  possibility  of  syphilitic  contagion;  and 
this  can  only  be  done,  especially  with  females,  by  indirect  interro- 
gation: it  is  still  more  important  to  ascertain  whether  there  have 
been  any  symptoms  of  syphilitic  poison,  such  as  sore  throat  or 


SYPHILITIC    ERUPTIONS.  403 

periosteal  inflammation:  the  circumstance  of  the  hair  falling  off,  or 
the  existence  of  iritis,  tends  to  the  same  conclusion. 

In  regard  to  the  eruption  itself,  we  notice  that  the  copper-colour 
is  not  limited  to  parts  which  are  already  healed,  except  perhaps  in 
urticaria;  and  the  disorder  does  not  exactly  correspond  to  any  of 
the. definitions  already  given:  it  approaches  nearer  to  one  than 
another,  and  may  simulate  any  of  them  except  the  vesicular,  which, 
if  it  ever  exist,  is  extremely  rare. 

The  urticaria  or  roseola  is  no  longer  a  simple  redness  of  the  skin, 
assuming  a  livid  hue  as  it  dies  away;  but  it  has  a  tendency  to 
desquamation — it  becomes  brown  instead  of  purple.  The  lichen  is 
larger  and  discoloured,  and  has  a  more  decided  scab  on  its  top ;  it 
approaches  more  nearly  to  the  characters  of  psoriasis.  The  squa- 
mous affection  again  is  much  less  scaly  and  more  tubercular;  the 
desquamating  cuticle  does  not  cover  the  entire  surface;  it  is  thin 
and  subordinate.  The  form  resembling  tubercle  does  not  present 
a  smooth  elevation,  which  gradually  subsides  into  the  tumid  skin 
around;  but  it  is  prominent,  covered  with  scales  or  crusts,  and  is 
scattered  over  the  body  in  place  of  being  aggregated  together. 

In  the  pustular  eruptions  the  analogies  are  closer,  but  still  the 
characters  are  defined.  If  resembling  impetigo,  it  forms  a  well- 
marked  ring,  the  suppuration  penetrates  deeper,  and  the  skin  around 
is  consequently  elevated.  If  it  seem  more  like  ecthyma,  we  shall 
have  a  difficulty  in  saying  that  it  is  not  rupia;  the  skin  is  deeply 
ulcerated,  and  a  thick  crust  forms  on  its  surface;  its  circumference 
is  round,  and  its  edges  high;  while  in  its  commencement  there  is 
neither  the  bright  redness  nor  the  occasional  mixture  of  blood  with 
the  pus,  which  is  common  in  ecthyma.  When  the  disease  assumes 
these  suppurative  forms,  ulceration  of  the  angle  of  the  lips  is  not 
uncommon,  and  greatly  confirms  the  diagnosis.  Its  discrimination 
from  rupia  is  less  important,  because  the  same  treatment  which  is 
called  for  in  the  one  is  equally  suitable  to  the  other;  but  it  is  less 
frequently  like  true  rupia  than  intermediate  between  that  and 
ecthyma. 

Coincident  with  any  of  the  foregoing  eruptions,  especially  when 
their  character  is  pustular,  we  sometimes  find  deep  burrowing  ulcers 
on  the  face,  and  at  the  alas  of  the  nose,  resembling  lupus,  or  there 
may  be  ozaena  from  commencing  disease  of  the  bones  of  the  nose, 
with  soreness  of  its  lining  membrane. 

Congenital  syphilis  is  chiefly  marked  by  ulcers  at  the  angles  of 
the  mouth,  cracked  lips,  running  of  the  nose,  "snuffles,"  condy- 
lomata, and  ulceration  of  the  anus  and  pudendum,  with  emaciation. 

In  reference  to  the  copper  colour  of  syphilitic  eruptions,  a  few  words  may  be 
added  on  the  subject  of  cutaneous  discoloration  generally.  As  an  objective  phe- 
nomenon it  forms  the  direct  exponent  of  purpura  and  of  jaundice,  and  is  the  chief 
feature  of  anaemia  and  chlorosis:  it  helps  us  to  distinguish  measles  from  scarlatina, 
and  it  materially  aids  our  diagnosis  of  cancer,  and  of  disease  of  the  heart  and  kidneys. 

In  other  cases  the  change  of  colour  is  more  distinctly  confined  to  the  skin  itself, 


IQ4  DISEASES   OF  THE   SKIN. 

.  ben,  for  example,  a  dusky  gray  or  blue  colour  is  produced  by  tbe  internal  use 
of  citrate  of  silver.     In  some  persons  the  existence  of  any  simple  cutaneous  dis- 
.,  herpe3,  lepra;  is  always  followed  on  its  decline  by  a  brown  stain,  which 
fter  the  skin  has  acquired  its  natural  condition  in  all  other  respects, 
and  this  is  particularly  the  case  with  persona  of  a  dark  complexion:  it  is  the  very 
same  change  as  is  seen  after  syphilitic  ail'  cept  that  the  colour  in  the 

latter  may  be  much  darker,  and  commonly  lasts  for  a  longer  period.  In  others, 
in,  patches  of  a  brown  or  yellowish  colour  form,  which  have  been  called  ephe- 
lidi  J,  from  their  supposed  connexion  with  sun  burning:  they  are  very  like  syphi- 
litic stains,  except  that  they  are  scarcely  so  dark,  and  they  have  not  been  preceded 
by  any  other  eruption.  In  their  commencement  they  resemble  pityriasis  versicolor, 
in  the  absence  of  branny  scales  and  roughness.  They  begin  with  small 
spots  like  freckles,  which  gradually  enlarge  and  coalesce,  forming  large  maculas 
which  have  not  the  circular  form  which  pityriasis  usually  presents. 

In  what  is  called  bronzed  skin,  the  whole  body  becomes  gradually  of  a  brown 
colour,  sometimes  variegated  here  and  there  by  portions  of  natural  colour.  Tim 
condition  has  been  thought  of  late  years  to  be  perhaps  connected  with  disease  of 
the  suprarenal  capsules. 

We  need  not  allude  to  the  congenital  peculiarities  of  naevi,  or  the  freckles  of 
early  life:  neither  does  the  deficiency  of  colour  in  the  albino  belong  to  conditions 
of  disease.  Occasionally  white  spots  are  developed  in  advanced  years,  especially 
on  the  scrotum  of  old  men  known  as  vitiligo,  the  true  nature  of  which  is  as  yet  not 
understood.     It  does  not  seem  connected  with  disease  properly  so  called. 

§  10.  Lupus  and  Scrofulous  Ulceration. — Though  generally  re- 
garded as  belonging  to  the  domain  of  surgery,  these  diseases  are 
evidently  of  constitutional  origin,  and  their  characteristics  ought  at 
least  to  be  known  to  the  physician.  There  seems  reason  to  believe 
that  they  belong  to  the  same  diathesis,  and  are  chiefly  modified  by 
the  age  of  the  patient.  They  are  marked  by  the  same  general 
feature  of  indolence  and  unwillingness  to  heal,  by  the  inefficiency 
of  local  treatment,  and  by  their  being  both  modified  by  the  same 
internal  remedies.  Lupus  is  more  distinctly  cutaneous ;  it  is  super- 
ficial, and  shows  a  great  tendency  to  spread.  Scrofulous  ulcer  is 
always  preceded  by  abscess,  and  can  only  be  regarded  in  a  second- 
ary sense  as  a  disease  of  the  skin. 

Lupus  may  arise  in  several  ways,  and  it  is  only  the  constitutional 
cachexia  which,  modifying  its  subsequent  course,  gives  it  a  specific 
character.  Its  seat  is  most  frequently  about  the  aire  of  the  nose, 
the  lips,  and  the  cheeks.  Its  commencement  may  be  referred  to 
three  principal  varieties  of  cutaneous  eruption,  the  vesicular,  the 
pustular,  and  the  tubercular:  occasionally  resembling  herpes,  it 
more  usually  begins  like  a  spot  of  impetigo;  and  when  it  attacks 
the  cheek,  it  sometimes  presents  the  form  of  tubercles.  In  the 
early  stage  it  differs  from  the  two  former  by  its  insidious  commence- 
ment and  slower  progress,  by  the  firm  adhesion  of  the  crust  and 
the  surrounding  tumefaction  of  the  skin,  and  its  dusky  colour. 
When  such  characters  mark  any  form  of  eruption  about  the  nose 
or  the  cheek,  it  is  not  improbably  lupus,  especially  if  scrofula  can 
be  traced  in  the  family:  if  it  be  lupus,  the  crust  covers  an  ulcera- 
ted surface,  which  very  soon  begins  to  spread.  From  tubercle  of 
the  skin  it  is  chiefly  distinguished  by  the  absence  of  the  bronze  tint, 
and  by  its  forming  a  defined  group  or  patch  on  one  cheek.     In  the 


ENDEMIAL   DISEASES    OF    THE    SKIN.  405 

majority  of  cases  of  lupus  scales  or  crusts  soon  form  on  the  surface, 
which  gradually  thicken  into  scabs,  and  leave  ulcers  behind  when 
removed ;  but  in  one  variety  the  disease  proceeds  without  any  ulcera- 
tion at  all,  the  destruction  of  the  skin  in  its  progress  being  marked 
by  seams  and  scars,  which  are  not  seen  in  tubercle:  such  cases  are 
naturally  less  distinct  than  those  in  which  ulceration  has  occurred. 

Scrofulous  ulceration  is  very  commonly  seen  in  the  side  of  the 
neck,  and  the  formation  of  an  abscess  there  must  always  be  re- 
garded with  great  suspicion.  Indolent  abscesses  in  other  parts  of 
the  body,  without  assignable  cause,  are  also  very  probably  due  to 
scrofula.  They  are  not  uncommon  on  the  back  of  the  hand,  and  in 
the  neighbourhood  of  the  elbow.  The  characters  by  which  scrofula 
is  recognised  have  already  been  discussed  (Chap.  IX.  Div.  I.  §  1 ;) 
and  we  may  here  call  to  mind  the  fact  that,  in  scrofulous  children 
the  cutaneous  eruptions  are  usually  of  the  suppurative  kind,  and 
are  remarkably  indolent  and  untractable:  impetigo  larvalis  is  one 
of  this  class;  they  often  excite  inflammation  and  enlargement  of 
the  cervical  glands,  which  may  be  the  first  beginning  of  scrofulous 
ulcer. 

Although  the  one  disease  be  most  common  in  childhood,  while 
the  other  occurs  at  adolescence,  or  after  maturity,  yet  occasionally 
scrofulous  ulcers  are  seen  in  adults,  and  lupus  at  a  very  early  age. 

The  ravages  of  syphilis  on  the  face  are  sometimes  closely  allied  to  lupus,  and 
there  is  every  probability  that  in  such  cases  the  scrofulous  diathesis  is  present  as 
well  as  the  syphilitic  taint:  it  is  recognised  by  its  coppery  tint,  aud  the  coexistence 
of  other  symptoms,  such  as  sore  throat,  eruption  on  other  parts  of  the  body,  &c. 
Syphilitic  lupus  is  quite  distinct  from  caries  of  the  bones  of  the  nose,  which  is  to 
be  regarded  as  a  specific  action  of  the  venereal  poison:  it  usually  results  in  ex- 
tensive ulceration  aud  great  disfigurement. 

We  have  to  distinguish  lupus  from  epithelial  cancer  of  the  lip,  which  usually 
commences  by  a  single  nodule,  and  gradually  increases  in  size  without  ulcerating, 
until  it  has  acquired  considerable  dimensions.  The  distinction  is  less  easily  made 
between  it  and  another  form  of  cancer  of  the  skin  in  the  early  stage,  when  there 
is  no  appearance  of  morbid  growth,  and  only  a  spot  of  ulceration,  which  subse- 
quently spreads  in  every  direction,  and  commits  frightful  ravages.  Subsequently 
the  distinction  is  less  difficult,  because  lupus  in  its  progress  leaves  scars  behind 
when  the  disease  has  subsided,  while  in  cancer  there  is  no  trace  of  the  healing 
process  at  all. 

Cancrum  oris  in  childhood  again  has  not  the  indolent,  sluggish  characters  whi<  h 
mark  all  the  preceding  conditions:  it  begins  with  ulceration  in  the  interior  of  the 
cheek,  which  spreads  with  great  rapidity,  producing  sloughing  and  destruction  of 
all  the  tissues  adjoining.  The  fetid  smell  and  rapid  progress  of  the  disease  pre- 
vents its  being  confounded  with  any  other  of  analogous  character. 

§  11. — Endemial  Diseases  of  the  Skin. 

Systematic  authors  refer  to  a  variety  of  diseases  as  inherent  in  various  localities, 
to  which  particular  names  have  been  assigned  in  the  districts  where  they  occur. 
Examination  of  the  statements  given  seems  to  prove  pretty  clearly  that  many  of 
them  are  referrible  to  syphilis  and  scrofula;  others  again  are  probably  varieties  of 
tubercle  of  the  skin,  which  is  much  more  liable  to  be  developed  in  warm  climates 
than  our  own;  the  worst  cases  seen  in  this  country  generally  occur  in  persons  who 
have  returned  from  India.  The  Arabian  Elephantiasis  consists  rather  in  hyper- 
trophy and  induration  of  the  cellular  tissue  than  in  auy  true  disease  of  the  skin. 
Such  disordei'S  need  not  occupy  a  place  in  these  pages,  because  they  are  so  rarely 
met  with,  and  are  not  likely  to  throw  any  difficulties  in  the  way  of  the  student. 


40G  DISEASES    OF   THE   SKIN. 

§  12.  Cellular  Inflammation. — Practically,  it  is  very  inconvenient 
that  we  arc  obliged  to  separate  this  disease  from  erysipelas,  when. 
Btadying  its  diagnosis:  and  to  make  the  distinctions  clear  we  ought 
to  hear  in  mind,  at  the  same  time,  the  characters  of  phlebitis,  se- 
condary suppurations,  and  even  erythema.  All  are,  more  or  less, 
allied  to  each  other,  but  yet  their  true  history  and  their  pathology 
present  them  to  our  notice  as  distinct  diseases. 

The  history  of  cellular  inflammation  classes  it  at  once  as  an  acute 
febrile  disease;  from  the  first  rigor  till  its  distinct  localization  there 
is  nothing  to  indicate  what  or  where  the  inflammation  is  to  be. 
Deep-seated  pain  first  calls  attention  to  the  part  affected,  and  is 
very  likely  to  be  referred  to  some  internal  organ,  because  it  has  not 
the"  burning  or  stinging  character  which  in  erysipelas  draws  the  at- 
tention of  the  patient  or  the  attendant  to  the  skin :  cases  of  this 
kind  have  been  treated  as  some  curious  or  anomalous  example  of 
internal  disease,  until  accident  has  revealed  the  mistake.  This 
lesson  should  not  be  forgotten.  The  skin  presents  a  lurid  redness, 
and  is  tense,  but  not  hard  to  the  touch;  pain  is  aggravated  by 
pressure,  but  there  is  not  much  superficial  tenderness ;  the  border 
of  the  redness  is  not  defined,  but  gradually  dies  away  in  the  sur- 
rounding skin.  These  characters  are  quite  sufficient  to  mark  the 
disease:  to  erysipelas  it  is  allied  by  the  fever  and  the  redness,  but 
the  colour  and  the  sense  of  touch  at  once  distinguish  it:  the  condi- 
tion of  the  skin  is  more  like  erythema,  but  there  is  no  fever  or  ten- 
sion in  that  disease.  From  the  swelling  accompanying  phlebitis  it 
is  completely  removed  by  the  redness  of  the  one  affection,  and  the 
white  oedematous  condition  of  the  other. 

It  may  be  one  of  the  forms  in  which  secondary  suppuration 
occurs;  and  it  may  give  rise  to  secondary  suppuration  elsewhere. 
In  both  cases  the  characters  of  pysemia  may  be  traced  in  addition 
to  the  cellular  inflammation ;  the  local  abscesses,  the  inflamed  ab- 
sorbents, and  the  profuse  perspirations,  suggest  to  the  observant 
practitioner  what  is  going  on. 

In  its  progress  suppuration  always  supervenes:  rigors,  which  have 
been  absent  since  the  commencement  of  the  attack,  recur,  and  are 
followed  by  sweating;  the  inflamed  surface  becomes  less  angry,  and 
assumes  a  more  livid  colour;  the  tension  subsides,  and  is  followed 
by  what  is  called  a  "boggy"  feeling,  which  is  partly  produced  by 
superficial  oedema,  partly  by  purulent  infiltration  and  deep-seated 
fluctuation. 

In  tracing  the  main  features  by  which  diseases  of  the  skin  are  to  be  discrimi- 
nated, and  applying  to  them  the  rules  of  diagnosis,  we  are  in  great  measure  re- 
stricted to  the  distinct  objective  phenomenon  which  each  case  presents  in  addi- 
tion to  its  other  and  more  general  symptoms.  In  many  cases  the  inspection  of 
the  eruption  is  all  that  is  wanted  to  determine  its  classification;  and  this  is  espe- 
cially true  of  what  may  be  called  typical  examples,  but  quite  as  frequently  our 
judgment  is  influenced  by  other  circumstances  which  the  history  of  the  case  re- 
is.  Practical  habitude  can  alone  give  the  power  of  determining  which  among 
these  have  any  direct  bearing  on  the  cutaneous  affection;  and  the  educated  eye 
can  often  determine  the  class  to  which  any  case  belongs  from  its  general  aspect 
and  history,  without  entering  on  a  minute  examination  of  its  specific  character. 


CELLULAR    INFLAMMATION.  407 

When  seeking  for  the  solution  of  a  difficulty,  subordinate  matters  must  not  be 
neglected,  such  as  the  station  in  life,  the  probability  of  hereditary  taint,  of  unsuit- 
able food,  or  of  exposure  to  infection,  which  the  appearance  and  manner  of  the 
patient  suggest.  With  this  object  the  physician  may  be  induced  to  ask  many 
questions  which  seem  to  have  little  to  do  with  the  skin:  unquestionably  in  a  great 
many  instances  it  is  true  that  the  more  correct  the  history  of  the  patient's  past  life, 
the  more  certain  is  the  diagnosis  of  any  particular  ailment.  I  will  add  a  few  illus- 
trations of  the  manner  in  which  these  additional  facts  afford  hints  for  our  guidance 
in  diagnosis. 

A  febrile  state  more  or  less  accompanies  erythema  and  roseola,  but  seldom  co- 
exists with  urticaria,  and  its  comparative  mildness  separates  these  from  erysipelas, 
phlegmon,  measles,  and  scarlatina.  It  distinguishes  the  acute  from  the  chronic 
form  of  eczema,  and  marks  the  boundary  very  often  between  eczema  impetiginodes 
and  true  impetigo.  It  draws  an  equally  clear  line  of  demarkation  between  pem- 
phigus and  rupia.  It  is  always  present  with  herpes,  but  when  the  fever  is  severe, 
the  eruption  is  certainly  only  subordinate  to  some  internal  disease.  Insufficient 
nutriment  or  exhaustion  of  body  cause  many  of  the  varieties  of  skin  disease  to  as- 
sume a  suppurative  character;  the  bearing  this  in  mind  will  often  lead  to  the  dis- 
covery of  the  true  original  lesidh  where  lichen,  eczema,  or  scabies  have  undergone 
such  a  change.  The  same  causes,  as  they  explain  the  presence  of  ecthyma  and 
rupia,  guard  against  the  needless  assumption  of  a  syphilitic  taint.  Poverty  and 
dirt  alike  go  hand  in  hand  with  scabies  and  prurigo,  but  with  the  latter  there  is 
poverty  of  blood  as  well  as  of  purse.  The  character  of  the  food  recently  taken  has 
often  a  definite  relation  to  urticaria.  The  habits  of  the  individual  and  the  condi- 
tion of  the  digestive  organs  have  a  close  relation  both  to  acne  and  tubercle  of  the 
skin. 

A  life  of  dissipation  affords  grounds  for  the  suspicion  of  syphilis;  and  it  is  espe- 
cially to  be  remarked  that  the  diseases  more  nearly  resembling  it  are  chiefly  of  a 
cachectic  character;  and  in  so  far  as  such  a  condition  is  opposed  to  a  life  of  gayety, 
does  the  suspicion  become  stronger,  that  the  eruption  is  specific,  if  the  idea  of  ca- 
chexia be  not  suggested  by  the  aspect  of  the  individual,  when  no  distinct  avowal 
of  primary  symptoms  can  be  obtained.  Close  confinement  and  impure  air  cer- 
tainly prepare  the  way  for  the  scrofulous  forms  of  disease  to  which  the  more  ob- 
stinate of  the  pustular  eruptions  have  been  with  justice  referred.  A  life  in  a  warm 
climate  is  much  more  likely  to  give  rise  to  tubercle  of  the  skin  than  to  lupus  or 
acne. 

The  probability  of  contagion  is  another  circumstance  which  sometimes  influences 
the  judgment.  It  must  be  remarked  that,  excluding  syphilis,  those  eruptions  only 
can  be  viewed  as  really  contagious  in  which  parasitic  life  is  concerned;  at  the 
same  time  there  are  sufficient  facts  to  make  us  hesitate  in  asserting  that  others  are 
not  propagated  in  the  same  way.  We  can  easily  conceive  that  pustular  matter 
reaching  an  abraded  skin  may  give  rise  to  suppuration  there,  and  the  disease  once 
excited  may  continue,  if  the  system  be  in  a  condition  likely  to  ensure  its  perma- 
nence: but  the  persons  who  seem  to  afford  instances  of  this  sort  of  contagion  are 
usually  exposed  to  the  same  influences,  whatever  they  may  be,  that  develop  the 
disease:  and  thus  the  spread  of  impetigo  through  a  family  or  a  school  is  no  proof 
that  it  was  communicated  from  one  child  to  another. 

The  mistake  more  frequently  made  is  that  of  assuming  that  impetigo  must  be 
either  favus  or  scabies,  as  it  happens  to  be  on  the  scalp  or  on  the  limbs,  because 
there  seems  to  be  good  evidence  of  its  having  spread  by  contact. 

Much  attention  must  not  be  paid  to  the  statement  that  the  eruption  itches  or 
causes  great  irritation,  as  a  guide  to  diagnosis.  The  susceptibility  of  the  skin 
varies  so  remarkably  in  different  individuals,  and  not  less  the  moral  courage  to 
resist  the  inclination  to  alleviate  the  distress  by  scratching,  which  seems  almost 
like  an  instinct  provided  for  the  purpose;  and  yet  we  all  know  how  very  greatly 
the  itching  is  increased  by  the  fresh  irritation  so  produced.  In  one  sense  the  in- 
formation is  of  use,  because  where  itching  is  complaiffed  of  we  may  be  sure  that 
the  inclination  has  been  indulged,  and  that  the  appearance  of  the  eruption  is  mo- 
dified by  it.  Xo  circumstance  tends  more  tn  create  varieties  among  the  forms  of 
skin  diseases,  and  a  great  many  .of  the  anomalous  examples  may  be  referred  to 
this  cause. 


INDEX. 


Abdomex,  Abscess  in,  113,  117;  Cancer  in,  119;  Diseases  of,  characters,  304; 
associations,  305 ;  Distended  or  retracted,  306  ;  Physical  examination  of,  306  ; 
inspection,  306;  palpation,  306;  percussion,  307;  Tubercles  in,  109;  Tumours 
in,  116,  306. 

Abortion,  99. 

Abscess,  Abdominal,  113,  117;  Hepatic,  340;  Of  lungs,  241  ;  Lumbar,  113;  Mus- 
cular, 390;  Psoas,  113;  Pytemic,  106;  Renal,  365;  Thoracic,  113,  116. 

Acarus  of  scabies,  397. 

Acephalo-cysts,  82,  119. 

Acinesis,  171. 

Acne,  399. 

Adipose  tissue,  hypertrophy  of,  113 ;  Adipose  diarrhoea.  347. 

iEgophony  as  a  symptom,  206;  term  objectionable,  209;  in  pleurisy,  243. 

Ague,  64  ;  Ague-cake,  347. 

Albuminuria,  366;  Anasarca  of.  86;  Chemistry  of,  358;  Causes,  368;  Complica- 
tions, 373  ;  -with  dropsy,  367  ;  with  hematuria,  97,  369 ;  with  morbus  cordis, 
285,  292,  368;  with  pregnancy,  368;  with  purulent  urine,  370;  Coma  in,  133; 
Epistaxis  in,  92  ;  Microscope  in,  355  ;  Without  dropsy,  368. 

Amaurosis,  100. 

Amcnorrhoea,  381;   Anremia  of,  103. 

Antemia,  101 ;  Anasarca  in,  103  ;  Blood-murmurs  in,  103 ;  Chlorosis,  103  ;  Dyspepsia 
from,  316  ;  Mania  with,  141. 

Anaesthesia,  171 ;  Numbness  of  other  kinds,  180. 

Analysis  of  urine,  349 ;  quantitative  and  qualitative,  348 ;  Table  of,  3G2. 

Anasarca,  86 ;  in  anremia,  103 ;  General  increase  of  size  from,  39 ;  the  type  of 
general  dropsy,  86. 

Aneurism,  293;  Abdominal,  295;  as  a  tumour,  118;  Of  arch  of  aorta  resembling 
laryngitis,  235;  Hrcniatemesis  from,  95;  Hemoptysis  from,  94;  Superficial, 
293 ;  Thoracic,  294 ;  as  a  tumour,  259. 

Angina  pectoris,  185;  from  dilated  heart,  286. 

Antimony,  poisoning  by,  78. 

Aortic  valves,  Disease  of,  291 ;  murmurs  in,  275,276-;  the  pulse  in,  43,  288. 

Aphonia  in  inflammation  of  larynx,  234 ;  Hysterical,  234. 

Aphthas,  300;  associated  with  diarrhcea,  385. 

Apoplexy,  159;  Coma  of,  132;  Paralysis  from,  174;  Poisoning,  simulated  by,  77; 
Pulmonary,  94;  Serous,  160:  Spinal,  176;  Transient,  134. 

Appearance,  general,  of  patient,  39. 

Appetite,  state  of,  39,  44. 

Arachnoid,  inflammation  of,  156. 

Arrangement  of  symptoms,  26. 

Arsenic,  poisoning  by,  78. 

Arteries,  diseases  of,  293;  of  brain,  degeneration  of,  158,  175. 

Ascarides,  84;  with  disordered  bowels,  327. 

Ascites.  88;  Causes  various,  86;  Distinguished  from  ovarian  dropsy,  91,  378;  from 
cirrhosis,  342;  from  mesenteric  disease,  118;  from  peritonitis,  334;   Produces 
local  enlargement,  112  :  Simulated  by  dilated  stomach,  313. 
Aspect  and  expression,  40,  45 ;  Malignant,  102. 

Asthma,  251 ;  with  empbysema,  252;  restriction  of  term,  252;  Hay  asthma,  252. 


410  INDEX. 

Auscultation,  195;  Kb  intricacies,  196;  practice,  195;  study,  102;  theory,  102; 
uses,  202,  205;  and  abuses,  19;  Of  Aneurism,  abdominal,  205;  thoracic,  294; 

superficial,  298;   Bl L-murmurs,  103,278;  Of  Heart,  270;  Modifications  of 

normal  Bounds,  27<»;  Murmurs,  diastolic,  275;  endocardial,  273;  friction,  272; 
Bystolic  at  apex,  270;  at  base,  277:  Summary,  '^78;  With  relation  to  endocar- 
ditis, 282;  dilatation,  286;  hypertrophy,  285;  pericarditis,  281;  valvular 
lesion,  286  ;  Of  lungs  with  percussion,  198  ;  Modified  breath  and  voice-sounds, 
:  in  clavicular  region,  198;  in  posterior  and  lateral  regions,  206;  Summary*, 
211;  Superadded  sounds,  195,  215;  continuous,  21G  ;  creaking,  217;  crepita- 
tion, 215;  crumpling,  217;  friction,  216;  gurgling,  216;  interrupted,  215; 
metallic  tinkling,  216;  moist  sounds,  21  (J;  sonorous  and  sibilant,  216;  succus- 
sion,  216;  in  Clavicular  region,  217;  in  posterior  and  lateral  regions,  222; 
Summary,  230;  With  reference  to  Bronchitis,  acute,  248;  chronic,  240;  Con- 
densation,  278;  Croup,  236;  Diseases  of  lungs  in  childhood,  263;  Effusion, 
243;  Emphysema,  250;  Empyema,  243;  Expansion  of  tissue,  270;  Hydro- 
pneumo-thorax,  247  ;  Hydro-thorax,  243;  Laryngitis,  234}  Phthisis  pulmonalis, 
252;  Pleurisy,  242;  Pleuro-pneumonia,  243;  Pneumonia,  237;  Pneumothorax, 
246;  Tuberculosis,  acute,  207;  Tumours  in  chest,  259. 

Btle,  faulty  secretion  of,  328;  in  excess  or  defective,  345. 

Bilious  headache,  160. 

Biliousness,  338;  analogy  to  dyspepsia,  338;  causes,  345;  erroneous  employment 
of  term,  314. 

Bladder,  calculus  in,  07,  371;  Catarrh  of,  distinguished  from  renal  abscess,  365; 
Distended,  as  a  form  of  abdominal  tumour,  92,  117;  Mistaken  for  ovarian 
dropsy,  378 ;  Producing  cystitis,  370;  Hemorrhage  from,  96;  Inflammation  of, 
370;   Paralysis  of,  179  ;   Rupture  of,  with  peritonitis,  331. 

Bladder,  Gall,  distention  of,  117;  With  gall-stones,  346. 

Blindness  in  amaurosis,  143  ;  in  disease  of  brain,  143;  in  hydrocephalus,  153. 

Blood,  Circulation  of,  in  disease  of  heart,  287;  mechanism  of,  275;  Chronic  blood- 
ailments,  100;  Depraved  states,  105;  their  effect  on  the  brain,  133;  Pus  in, 
106;  Spitting  of,  93;  in  aneurism,  95;  in  disease  of  heart,  94;  in  phthisis, 
111;  Urea  in,  134;  Vomiting  of,  95;  White-cell,  102. 

Blood-ailments,  chronic,  100. 

Blood-murmurs,  anaemic,  103.     See  Bruits. 

Bones,  Caries  of,  113;  in  head,  154;  Diseases  of,  388;  Fragilitas,  389;  Growths 
from,  120;  in  chest,  261 ;  Inflammation  of,  113,  388  ;  Mollities.  380;  Rachitis, 
389. 

Bothrio-cephalus  latus,  83. 

Bowels,  Constipation  of,  320;  Diarrhoea,  324;  Diseases  of,  319;  Disordered,  327; 
Dysentery,  325  ;  Enteritis,  320;  Hemorrhages  from,  98,  327  ;  Ileus  and  Intus- 
susception, 321 ;  Inflammation  generally,  319;  Obstruction,  323 ;  in  enteritis, 
322;  causes  and  diagnosis,  323;  Perforation,  330;  Quantity  of  bile  as  affecting, 
345;   Symptoms  from,  general,  39;  special,  44;   Ulceration,  326;  in  fever,  55. 

Brain,  diseases  of,  149;  Acute,  149;  Apoplexy,  159;  Chronic,  157:  with  active 
symptoms  supervening,  150;  Functional  disturbance,  164;  General  indications, 
128;  inflammation,  simple,  154;  delirium  of,  130;  scrofulous,  150;  delirium 
of,  137;  Paralysis  from,  148;  distinguished  from  disease  of  nerves,  174;  Modes 
of  investigation,  165;  Pathology  of,  131;  concussion,  132,  133;  extravasation 
of  blood,  132;  serous  effusion,  133;  Semeiology  of,  130;  coma,  132;  delirium, 
134;  insomnia,  134;  mental  phenomena,  131;  muscular  movements,  146;  para- 
lysis, 147;  spasm,  147;  sensibility,  142;  stupor,  133;  Rheumatism  in  con- 
nexion with,  US,  70;  metastasis,  137;  Sympathetic  irritation  of  stomach,  312; 
Tubercles  in,  112,  152;   Tumours  of,  174. 

Breath-sound,  105;  Abolished,  204;  Modified,  196;  in  clavicular  region,  198;  in 
posterior  and  lateral  regions,  206  ;  Obstructed  in  condensation,  212;  in  expan- 
sion, 213.     See  Auscultation. 

Brighfs  disease,  366.     See  Albuminuria. 

Bronchitis,  Acute,  247 ;  auscultatory  phenomena,  248 ;  compared  with  influenza, 
2  IS;  with  pneumonia  and  phthisis,  2  18;  complicating  pleurisy,  243;  Chronic, 
2  IS:  auscultatory  phenomena.  240;  complications,  249;  with  emphysema,  251  ; 
simulating  phthisis.  2  10,  258;  of  Childhood,  264;  of  Fever,  55;  of  Heart- 
disease,  201  ;   Modified  breath-sound  in,  204;  Superadded  sound  in,  225,  226. 


INDEX.  411 

Bronchocele,  116. 

Brouchorrhoea,  2-50. 

Bronchus,  dilated,  202,  204. 

Bruits  all  produced  in  the  blood,  104;  Cardiac,  270;   "De  diable,"  105;  its  value, 

279;   Valvular  contrasted  with  ansemic,  278. 
Bursas,  enlarged,  202,  204. 

Causes  of  morbid  phenomena,  complex,  23. 
Cachreniia,  105. 

Cachexia,  105;  antenna  from,  101;  of  cancer,  119;  in  skin  disease,  391. 
Calculus,   Biliary,  345;  passage  of  a  gall-stone,  346;  simulating  peritonitis,  346 
Renal,  3  \4  :'  exciting  hemorrhage,  97  ;  simulating  peritonitis,  332:  Vesical,  371 
Cancer,  Abdominal,  92;  of  liver,  341,  343  ;  of  pancreas,  347;  of  peritoneum,  336 
of  stomach,  96,  311;  its  situation,    117;   of  uterus,  386;   Complexion  in,  102, 
117;  Osseous,  119;  Thoracic,  119;  Varieties,  colloid,  119;   encephaloid,  119 
epithelial,  115;  fungoid,  119;  scirrhus,  119;  their  diagnosis,  120. 
Cancrum  oris,  300,  405. 
Caries,  388  ;  Of  spine,  Causing  inflammation  of  cord,   168 ;  lumbar  abscess,  113 ; 

paralysis,  175:   Simulating  rheumatism,  72. 
Carnification  of  lung  tissue,  212. 
Catheter,  manipulation  of,  366. 
Cellular  tis-ue,  inflammation  of,  406. 

Chest,  general  symptoms  of  disease  in,  129,  188;  Examination  of,  188  ;  Alterations 
in  form,  193  ;  in  movement,  193  ;  Auscultation,  195 ;  Percussion,  194  :  Physical 
signs,  192;  Tumours  of,  259.  See  Auscultation,  Percussion,  Lung*,  §c. 
Children,  Convulsions  of,  147,  162;  Diarrhoea  of,  325;  Diseases  of  brain  in,  151, 
164;  symptoms  of,  137  ;  Diseases  of  lungs  in,  263  ;  of  skin  in,  394:  scrofulous, 
404;  syphilitic.  402:  Fevers  of,  152:  remittent,  56;  eruptive,  61  ;  Hoarseness, 
its  importance.  256  ;  Hooping-cough,  262;  Thrush,  300;  Tracheitis  and  crowing 
inspiration,  256;  Ulcer  of  mouth  in,  300. 
Chlorosis,  96  ;  Pain  in  side  in,  183. 

Cholera,  English,  58;  Epidemic,  58;  Mortality  in,  as  relating  to  diagnosis,  59. 
Chorea,  124;  Brain  in,  146,  165;  Heart-disease  in,  288;  From  worms,  83. 
Circulation,  with  reference  to  murmurs,  287;  Mechanism  of,  275. 
Cirrhosis  of  Liver,  342 ;  evidence  of  previous  inflammation,  340 ;  indicated  by  ascites, 

343;  not  a  cause  of  jaundice,  344. 
Classification  of  Diseases,  20  ;  of  Fevers,  52,  54 ;  of  spots  in,  53 ;  of  Eruptive  fevers, 
61 ;  Chronic  blood-ailments,  100;  Depraved  constitutional  states,  108;  Paralysis, 
173.     See  also  Diseases.     Of  Symptoms,  26  ;  General  indications.  36  ;  from  re- 
gions and  organs,    127;    Special  indications,  43;    of  Brain-disease,   130;   of 
Delirium,  136;  of  Heart-disease,  266;  diastolic  murmurs,  275;  systolic  mur- 
murs at  apex,  276  :  at  base,  277  ;  of  Lung-disease,  198  ;  modified  breath  and 
voice-sounds,  199,  206;  superadded  sounds,  215:    of  Symptoms  derived  from 
the  urine,   349 ;   chemical  relations,   table  of,  362 ;  sediments,   353,   355 ;  Of 
Tumours,  115. 
Clavicular  region,  modified  sounds,  198;  superadded  sounds,  217. 
Clinical  Clerk,  outline  of  notes  for,  viii. 

Colic,  from  constipation,  320;  Lead,  80;  Simulating  nephralgia,  364. 
Colica  Pictonum,  80. 

Collapse  in  cholera,  58;  in  peritonitis,  330. 

Coma.  132;  of  apoplexy,  132,  160;  of  poisoning,  77;   Partial,  133. 
Complexion  as  a  symptom,  39,  45;  in  blood  diseases,  102. 
Concussion  of  brain  with  coma,  132;  with  stupor,  134. 
Condensation  of  lung-tissue,  212. 
Condition  of  patient,  general,  36. 

Constipation,  320;  in  disease  of  brain,  155;  inducing  obstruction,  323;  in  perito- 
nitis, 332. 
Convulsions,  Apoplectic,  30;  Attendant  on  false  croup.  237:  in  Brain- disease,  156; 
functional,  165;  in  Childhood.  147,  162;  Distinguished  from  epilepsy,  162;  Ge- 
neral, 146;   with  paralysis,  174. 
Cord,  spinal,  168;  Chronic  disease  of,  169;  Inflammation  of,  168;   Paralysis  from 

apoplexy  of,  177;  from  disease  of,  174,  175;  from  injury  of,  176. 
Coronary  arteries,  disease  of,  186. 


412  INDEX. 

Coryza,  61. 

Cougb.  absent  in  acute  laryngitis,  233;  Characters  of,  100;  in  chronic  laryngitis, 

I;  in  croup,  286;  with  elongated  uvula,  3U2;  Hooping-cough,  262. 
Crump*  in  cholera,  59. 

Crepitation,  252;  in  pneumonia,  22^:  not  infallible,  19,  239. 
Group,  236;  causing  laryngitis,  234;  distinguished  from  laryngitis,  237 ;  false,  237; 

hoarseness  in,  237;  tracheotomy,  237. 
Crowing  inspiration,  287. 
Cysticercus,  84. 
Cysts,  Acephalo-,  119:   Hydatid,  116,  118;  contains  a  parasite,  86;  Ovarian,  37G ; 

Serous,  120;  causing  local  dropsy,  80;  distinguished  from  ascites,  90. 
Cystitis,  370. 

Deafxess.  in  disease  of  brain,  144;  in  disease  of  fauces,  301;  in  fever,  13G;  in  hy- 
drocephalus, 152. 

Delusions,  140. 

Delirium,  134;  in  erysipelas,  137;  in  fever,  54,  136;  in  insanity,  139;  in  pneumo- 
nia, 137;  in  rheumatism,  68,  137;  in  simple  inflammation,  139,  154;  in  tuber- 
cular inflammation,  138;  Passive,  138:  Points  to  cerebral  disease,  138;  Re- 
ferred to  reflective  faculties,  131;  Sub-divisions,  135;  Tremens,  126,  136;  dis- 
tinguished from  insanity,  140;  With  subsultus  in  fever,  146;  With  tremor  in 
delirium  tremens,  146. 

Diabetes,  371;  insipidus,  370;  tests  for  urine  of,  360;  thirst  of,  with  hunger,  39. 

Diable,  bruit  de,  106. 

Diagnosis,  abuse  of,  18;  advance  of,  192;  caution  in,  304;  difficulties  of,  118,  130 
errors  of,  24,  230,  239;  fancied  excellence  of  accuracy,  386;  general  indica 
tions  in,  35,  127;  illustrations  of,  from  geometry,  22;  method  of,  25.  28 
neglect  of,  18,  391;  object  of,  21,  23;  peculiar  cases,  122,  25'.'.  379;  province 
of,  17;  relation  to  theory  of  disease,  22;  special  indications,  42;  theory  of,  21 
uncertainty  of,  290,  308. 

Diarrhea.  324;  adiposa,  306;  bilious,  305;  chronic,  325;  choleraic,  59;  febrile,  324 
ordinary,  324;  Associations,  324;  with  fever,  55;  with  phthisis,  110;  in  Child- 
hood, 321. 

Diathesis,  Hemorrhagic,  distinguished  from  purpura,  100;  with  epistaxis,  92;  with 
ha?maturia.  97  :  with  uterine  hemorrhage,  99;  Scrofulous  and  Tubercular,  108; 
with  delirium,  137;  with  inflammation  of  brain,  150. 

Digestive  organs,  derangements  of,  309;  Indications,  232. 

Digitalis,  poisoning  by,  78. 

Dilatation  of  stomach,  313. 

Diphtheritis,  303  ;  leading  to  croup,  236. 

Disease,  theory  of,  17,  23. 

Diseases,  Acute  and  chronic,  32;  Classification,  29;  of  adventitious  origin,  75;  of 
arteries,  293;  of  brain,  149;  of  bones,  388;  of  cellular  tissue,  400;  of  chest, 
180;  chronic  blood-ailments,  100;  depraved  constitutional  states,  108:  febrile, 
48;  gout,  72;  of  heart,  280;  of  intestinal  canal,  319;  of  joints,  388;  of  kidneys, 
363;  of  liver,  338;  of  lungs  in  childhood,  203;  of  mouth  and  pharynx,  299;  of 
muscles.  389;  of  nerves,  181;  of  oesophagus,  308;  of  ovaries,  376;  of  pancreas, 
347;  paralysis,  171;  of  peritoneum,  330;  quasi-nervous,  122:  of  respiratory  or- 
gans, 232;  rheumatism,  66;  of  skin,  391;  of  spinal  cord,  168;  of  spleen,  346; 
of  stomach,  308;  of  urinary  organs,  363;  of  uterus  and  vagina,  381;  of  varia- 
ble seat,  85;  of  veins,  296;  Simulated  in  hysteria,  124;  epilepsy,  163;  para- 
lysis, 172,  178;   Table,  29. 

Distention  of  stomach,  315. 

Distoma,  84. 

Distortion  of  chest,  193. 

Diuresis,  370. 

Dropsies,  103  ;  Encysted,  90.  » 

Dropsy,  Acute,  87;  as  a  symptom,  39;  Chronic,  87:  Ovarian,  112.  376;  With  ance- 
mia,  103;  with  disease  of  kidney,  308,  375;  of  heart,  280,  291;  of  liver,  344; 
of  peritoneum.  334;  with  pregnancy,  368. 

Drop-wri>t,  82,  17'.'. 

Drunkards,  disease  of  liver  in,  372;  of  stomach,  311;  Dyspepsia  of,  317;  Delirium 
of,  120;  Biliousness  in,  339. 


INDEX.  413 

Duration  of  disease,  32 ;  and  sequence  of  phenomena,  33. 

Dysentery,  acute,  325;  chronic,  326;  Hemorrhage  in,  98. 

Dysmenorrhoea,  382. 

Dyspepsia,  313;  Associations  of,  313,  318;  Complex  cases,  314,  317;  Connexion 

with  brain-disease,  160  ;  Diagnosis  by  exclusion,  309;  General  characters,  308; 

Palpitation  of,  166;  Simulating  gall-stones,  34G;  Sympathetic  affections,  309; 

Varieties,  314;  from  abuse  of  stimulants,  318;  of  tobacco,  318;  anajmic,  102, 

316;  of  drunkards,  317;  from  distention,  315;  faulty  secretion,  310;   gouty, 

317;  hyperasmic,  316;  from  irritability,  314. 
Dysphagia  in  aneurism,  236;  in  croup,  236;  in  diseases  of  mouth  and  pharynx, 

299;  in  laryngitis,  235;  in  stricture  of  the  oesophagus,  309. 
Dyspnoea  as  characteristic  of  emphysema,  249 ;  of  pleurisy,  222 ;  of  heart-disease, 

280;  indicating  disease  of  the  chest,  190;  peculiar  in  laryngitis,  233;  and  croup, 

236. 

EcnTNO-coccns,  82. 

Ecthyma,  399;  connexion  -with  rupia,  400. 

Eczema,  396;  impetiginodes,  397,  398. 

Effusion,  Abdominal,  88;  evidence  of,  by  fluctuation,  89;  Causes  of,  91;  General 
and  local,  86;  cause  of  enlargement,  45,  112;  Pleuritic,  193;  auscultation  in, 
206;  symptoms  of,  242;  In  Ventricles  of  brain,  138;  hydrocephalus,  151;  serous 
apoplexy,  160. 

Elephantiasis  of  the  Greeks,  402;  of  the  Arabians,  405. 

Emaciation,  59,  190. 

Emphysema,  39;  of  Lungs,  250;  auscultation  in,  203,  210;  complication  with  asth- 
ma, 251;  with  bronchitis,  251;  distinguished  from  pneumo-thorax,  247;  gene- 
ral symptoms,  249. 

Empiricism,  21. 

Empyema,  112,  116;  auscultation  in,  208;  symptoms  of,  243. 

Enchondroma,  120. 

Endocarditis,  282;   rheumatic,  68,  283;  distinguished  from  old  disease,  284. 

Enlargements,  local,  112;  general,  45. 

Enteritis,  321;  from  obstruction,  321;  with  peritonitis,  333;  its  relative  frequency, 
319. 

Entozoa,  82. 

Ephelides,  404. 

Epilepsy,  162;  Distinguished  from  apoplexy,  160;  from  convulsions,  162;  from  hys- 
teria, 124;  from  poisoning,  77;  Feigned,  163;  General  indications,  147;  Hyi 
teric,  124,  163;  with  Worms,  83. 

Epistaxis,  92,  93. 

Eruptions  on  skin,  colour  of,  404;  early  stage  of,  392;  observation  of,  129;  In  Fe- 
ver, 53;  Scrofula,  108,  404;  Syphilis,  79,  402;  Varieties  of,  see  Skin-diseases. 

Erysipelas,  61,  63;  analogy  to  puerperal  fever,  331;  delirium  of,  137;  metastasis, 
137;  of  throat,  causing  oedema  glottidis,  234. 

Erythema,  392  ;  nodosum,  106,  392. 

Evidence  of  disease  of  lungs,  basis  of,  196. 

Examination  of  patient,  general  plan,  26;  of  abdomen,  244;  of  chest,  188;  of  heart, 
26&;  of  lungs,  196,  215;  of  regions  and  organs,  127;  of  urine,  348. 

Expectoration,  characters  of,  19(1. 

Expression  and  aspect  of  patient,  40. 

Eyes,  changes  in,  142;  contraction  and  dilatation  of  pupils,  143;  perversions  of  vi- 
sion, 143;  ptosis,  148;  strabismus,  147,  148. 

Facultiks,  mental,  as  indications  of  disease,  131. 

Fasces,  Accumulation  of,  in  constipation,  320 ;  in  obstruction,  323 ;  simulating  tu- 
mour, 117;  Characters  of,  in  cholera,  59;  in  disordered  bowels,  328;  in  dysen- 
tery, 326;  in  jaundice,  344;  Special  indications  from,  43;  fatty,  328;  yeasty, 
328. 

Fai-cv,  acute,  147. 

Fat,  deposit  of,  39,  112. 

Fatty  degeneration  of  heart,  286 ;  of  muscles,  389. 

Fauces,  diseases  of,  300;  inflamed  in  croup,  237;  in  laryngitis,  232;  ulceration  of, 
302. 


s- 


414  INDEX. 

Favus,  101. 
Febrioala,  60. 
Febrile  diseases,  48. 

ned  epilepsy,  168;  paralysis,  172,  180;   paraplegia.  178. 
Fermentation  in  the  intestine,  828;  in  the  stomach,  818;  mine  of,  860. 
Fever.  Continued,  60;  classifications,  62,  68,  6  I ;  complications,  54;  deafness  in,  130; 

delirium,   186,  188,  163;  peritonitis,  888;  pneumonia,  241;  resembling  acute 

phthisis,  110;  sub<ultus,  145;  typhoid,  ■">:;,  56;  typhus,  50,  100;  urine  of,  373; 

of  Children,   •"><;.   162;   Eruptive,  60;   Hectic,  11 1,  189;   Intermittent,  03,  155; 

Puerperal,  331;  Remittent,  50;  Scarlet,  01;  Yellow,  96. 
Fevers  in  general,  50;   subdivisions,  29. 
Filiaria,  84. 
Floccitatio,  145. 
Fluctuation,  89. 

Formication,  170;  differs  from  anaesthesia,  180. 
Fragilitas  ossium,  389. 
Frambcesia,  402. 
Fremitus,  vocal,  198. 
Friction-sounds  in  Heart,  272;  characters  of,  273;  in  pericarditis,  281;  in  rheumatic 

fever,  283;  in  Pleura,  210;  its  position,  217,  222;  in  pleurisy,  242. 
Fungoid  growtbs,  119;  a  cause  of  haemoptysis,  95. 

Gall-bladder,  distended  with  bile,  116;  with  concretions,  345. 

Gall-stones,  345;  passage  of,  346. 

Gangrene  of  lungs,  241. 

Gaseous  poisoning,  78. 

Gastritis,  chronic,  312;  idiopathic,  312;  its  rarity,  319;  resulting  from  poison,  312. 

Glands,  enlargement  of,  115;  from  Morbid  growth,  117;  in  abdomen,  336;  in  chest, 
259:  from  Scrofulous  deposit,  108;  in  abdomen,  109;  in  chest,  204;  in  the  neck, 
303 ;  from  Skin-disease,  404 ;  Sub-maxillary,  inflamed,  303. 

Glanders,  80,  107. 

Globus  hystericus,  124. 

Glottis,  oedema  of,  234. 

Goitre,  115. 

Gonorrhoea,  75;  distinguished  from  leucorrhcea,  383;  giving  rise  to  cystitis,  370; 
obscuring  diagnosis  in  examination  of  urine,  383. 

Gout,  72;  alteration  of  joints  from,  389;  distinguished  from  rheumatism,  68;  dys- 
pepsia of,  317;  erratic,  73;  in  the  stomach,  34$;  masked,  186;  nephralgia  of, 
304;  retrocedent,  186;  rheumatic,  73,  389. 

Growths,  morbid,  112;  from  bone,  120;  in  chest,  259;  cystic,  119;  in  liver,  341;  ma- 
lignant, 116,  119;  myeloid,  120;  in  peritoneum,  336. 

Habits  of  patient,  32. 

Haematemesis,  95;  in  disease  of  stomach,  311;  distinguished  from  haemoptysis,  95. 

Hematocele,  112. 

Hematuria,  90;  with  albuminuria,  369;  causes,  369;  microscopic  appearances,  355. 

Haemoptysis,  93,  110;  in  disease  of  heart,  291 ;  hysterical,  93;  iu  malignant  disease, 

200:  in  phthisis,  253;  in  pneumonia,  237. 
Hemorrhage,  92;  from  bladder,  97;  from  kidney,  97,  355;  from  intestines,  98,  327; 

from  lungs,  94,  110;  from  nose,  92;  from  prostate  gland,  98;  from  stomach,  96, 

312;  from  uterus,  98;  An;emia  from,  101;  Hysterical,  93;   Internal,  100;  with 

Purpura,  100;  Subcutaneous,  100;  Vicarious,  95. 
Hemorrhagic  diathesis  differs  from  purpura,  100;  With  epistaxis,  92;  hematuria,  97; 

uterine  hemorrhage,  99. 
Hallucinations.  141,  144. 
Hay-asthma,  252. 
Headache  as  a  symptom,  145;  dyspeptic,  166;  in  constipation,  320;  in  inflammation 

of  brain,  155;  in  chronic  disease,  158. 
Head  symptoms,  149',  165;  increased  or  diminished  by  horizontal  posture,  145. 
Hearing,  alteration  in  sense  of,  144. 
Heart,  Diseases  of,  280;  acute  and  chronic,  280;  adherent  pericardium,  268,  281; 

congenital,  290;  dilatation,  286;  endocarditis,  282;  fatty,  280,  389;  hypertrophy, 

285;  pericarditis,  281;  valvular  lesion,  286;  aortic,  291;  mitral,  290;  Ausculta- 


INDEX.  415 

tory  phenomena,  270;  altered  rhythm.  271 ;  modification  of  normal  sounds,  270; 
murmurs,  270;  diastolic,  275;  endocardial,  273;  friction,  272  ;  musical,  290; 
systolic  at  apex,  276;  at  base,  277;  "to  and  fro,"  272;  valvular  and  ana?mic, 
278;  nomenclature  faulty,  270;  reduplication,  271;  Associations,  292;  with  an- 
gina, 185;  brain-disease,  161;  chorea,  289;  dropsy,  86;  epistasis,  93;  ha^mop- 
tysi-.  94;  kidney-disease,  368;  rheumatism,  68,  283;  its  metastasis,  137;  Causes 
of  disease,  292 ;  Delirium  in  inflammation  of,  137 ;  Evidence  of  alteration  of  size, 
267;  enlargement,  267,  269;  irregular  action,  267,  269;  intermission,  268;  Ex- 
amination of,  266;  Foetal,  sound  of,  379;  General  indications,  12'.),  188;  Me- 
chanism of  circulation,  275;  explanatory  of  bruits,  287;  Nervous  palpitation, 
268,  271;  Normal  sounds,  266;  Pulse  in  disease  of,  43,  288;  Simulation  of  fluid 
in  pericardium,  268,  284. 

Hectic,  110,  190. 

Hemicrania,  185. 

Hemiplegia,  148,  173. 

Hepatitis,  339;  with  pleuro-pneumonia,  340. 

Hernia,  115;  internal  strangulation,  323. 

Herpes,  397;  circinatus,  397;  labialis,  397;  preputialis,  397;  zoster,  397. 

History  of  case,  its  meaning,  25 ;  its  importance,  32. 

Homoeopathy,  24. 

Hooping-cough,  232;  symptoms,  261;  complications,  262. 

Hydatids,  119;  connected  with  the  echino- coccus,  82;  distinguished  from  ascites,  91, 
in  liver,  341,  342;  position,  116. 

Hydrencephaloid  disease,  153. 

Hydrocele,  112. 

Hydrocephalus,  acute,  112,  151;  chronic,  112. 

Hydrocyanic  acid,  poisoning  by,  78. 

Hydrometra,  91,  378. 

Hydropathy,  24. 

Hydropericardium,  284;  simulated  by  dilatation,  208,  285. 

Hydrophobia,  79. 

Hydro-pneumo-thorax,  246. 

Hydrothuras,  112;  from  albuminuria,  244;  auscultatory  signs,  209;  from  acute  pleu- 
risy, 242;   passive,  244. 

Hyperemia  of  stomach,  340. 

Hyperesthesia,  169. 

Hypertrophy,  simple,  112. 

Hypochondriasis,  122. 

Hysteria.  122:  in  men,  122;  its  pathology,  376;  sensations  of  pain  in,  142. 

Hysterical  chorea,  125;  epilepsy,  163;  haemoptysis,  93,  95;  laryngitis,  235;  neu- 
ralgia, 183,  187;  paralysis,  123,  165;  tetanus,  125 ;  tympanites,  329. 

Hunger,  39,  44. 

Icterus,  see  Jaundice. 

Ichthyosis,  395. 

Idiosyncrasy,  19. 

Ileus,  321. 

Illusions,   141. 

Impetigo,  39S;  figurata,  398;  sparsa,  398. 

Incoherence,  134. 

Inconsistency  of  history,  26 ;  of  phenomena,  33. 

Inflammation,  accompanied  by  pain  and  tenderness,  141;  of  brain,  delirium  of,  139; 
not  synonymous  with  pain,  123;  nor  with  neuralgia,  182;  ovarian  disease  inde- 
pendent of,  376;  suppuration,  113;  of  uterus,  rarity  of,  386. 

Influenza,  57;  an  ephemeral  fever,  52;  relation  to  bronchitis,  247;  simulated  by 
phthisis,  109. 

Innervation,  131. 

Insanity,  as  a  symptom,  131;  delirium  of,  139;  nature  of,  140;  perverted  sensations 
in,  142;  puerperal,  141. 

Insensibility,  132. 

Insomnia,  134;    attendant  on  delirium,  134;   in  delirium  tremens,  136. 

Intermittents,  63;  hemicrania  as  a  form  of,  185. 

Intestinal  canal,  diseases  of,  319;  their  classification,  319;  Constipation,  320;  Diar. 


41G  INDEX. 

rhna.  •'•-I;  Disordered  bowels,  827;  special  forms  of,  828;  Dysentery,  325;  En- 
teritis, 821  :  Hemorrhage,  98;  Ileus,  821;  Obstruction,  822;  its  investigation  and 
c.,,.  Relations  of  inflammation,  819;  its  importance  in  semeiology,  319; 

Tympanites,  828;  Ulceration,  326. 

Intolerance  of  li.nht.  148. 

Intoxication,  its  distinction  from  apoplexy,  132;  from  narcotic  poisoning,  77. 

Intue  Busception,  821. 

Irritation,  nervous,  184;  spinal,  168. 

Irritability  of  stomach,  314. 

Ischuria,  866. 

Itch,  "grocer's,"  397. 

Jaundice,  8  13;  accidental,  312  ;  its  colour  simulated,  343;  produced  by  biliary  cal- 
culus, 34(1;  by  emotion,  344;  by  hepatitis,  339;  its  theory  not  always  under- 
stood, 343;  varieties,  344. 

Kidneys,  Diseases  of,  363;  abscess  of,  365;  albuminuria,  366;  calculus,  97,  364; 
diabetes.  371;  diuresis,  370;  functional  disorder,  372;  ischuria/ 366 ;  nephritis 
and  nephralgia,  363;  Associations  of,  374;  with  brain  disease,  161;  -with  dropsy, 
86,  375;  with  dyspepsia,  374:  with  gout,  73;  with  hydrothorax,  244;  with  hy- 
pertrophy of  heart,  285;  with  oedema  of  glottis,  234;  with  rheumatism,  72; 
Bleeding  from,  369;  its  varieties,  97;  Bright' s  disease,  366;  Examination  of 
urine,  348;  table  of  chemical  relations,  362;  Fungus  of,  97;  General  state,  re- 
lation of  urine  to,  38;  General  symptoms,  129;  the  Lithic-acid  diathesis,  373; 
the  Phosphatic  diathesis,  373.     See  Urine. 

Kiestine  in  urine,  375. 

LAKYxr.iTis.  acute,  233;  bastard,  234;  chronic,  235;  from  disease  of  bone,  235; 
idiopathic,  234;  from  injury,  234;  from  quinsy  or  croup,  234;  syphilitic,  235; 
tubercular,  235 ;  Aphonia  of,  234  ;  Distinguished  from  aneurism,  235 ;  from 
croup,  237;  Simulated  in  hysteria,  228;  by  tumour,  261. 

Laryngismus  stridulus,  see  Crowing  Inspiration. 

Lead,  poisoning  by,  81 ;  paralysis  of,  179,  386. 

Lepra,  395. 

Leucocytlueniia,  102. 

Leucorrhoea,  383  ;  its  causes  and  source,  383 ;  in  children,  vaginitis,  383. 

Lichen,  393:  agrius,  394;  circumscriptus,  394;  strophulus,  394. 

Liver,  diseases  of,  338  ;  abscess,  340  ;  cancer,  119;  cirrhosis,  342  ;  congestion,  340; 
enlargement,  341;  fatty,  341;  "hobnail,"  342;  hydatid  cysts  of,  119,  341; 
inflammation  of,  339;  jaundice,  343;  lardaceous,  341;  "nutmeg,"  341;  scirrhus 
of,  343;  tumours,  116;  yellow  atrophy,  343;  Ascites,  caused  by,  91,  343; 
Associations,  345 ;  Faulty  secretion,  345 ;  Gall-stones,  345 ;  Eiematemesis  from, 
96 ;   Obscurity  of  symptoms,  338. 

Lumbago,  70. 

Lumbrici,  83. 

Lungs,  Auscultation  of,  198,  215;  in  clavicular  region,  modified  breath  and  voice 
sounds,  199;  superadded  sounds,  217;  in  posterior  and  lateral  regions,  modified 
sounds,  20G;  superadded  sounds,  222;  summary  of  modified  sounds,  211;  of 
superadded  sounds,  230;  Condensation  of,  212;  carnification,  212:  compression, 
2ii'.';  consolidation,  evidence  of,  196;  compared  with  compression,  209;  hepati- 
zation, 212;  tuberculization,  212;  Diseases  of,  232;  abscess,  241;  apoplexy,  94; 
asthma,  251;  bronchitis,  247;  emphysema,  249;  gangrene,  241;  inflammation, 
237;  chronic,  241;  phthisis,  253;  pleurisy,  242;  pleurodynia,  245;  pleuro-pneu- 
monia,  243;  pneumonia,  237;  pneumo-thorax,  245;  suppuration,  191;  tumours, 
193;  Diseases  in  childhood,  263;  Expansion  of,  213;  General  indications.  129, 
188;  Percussion,  194,  198;  with  modified  sounds  in  clavicular  region,  198;  in 
posterior  and  lateral  regions,  206 ;  with  superadded  sounds  in  clavicular  region, 
217;  in  posterior  and  lateral  regions,  222;  Physical  examination,  193;  precedes 
that  of  heart,  192;  Special  external  signs,  194;  Tubercles  in,  105;  at  both 
apices,  257:  at  base,  257;  detection  in  early  stage,  201,  220;  distinguished  from 
inflammation,  240;  relation  of  sounds  to,  256. 

Malaise,  142. 

Malaria,  185. 


INDEX.  417 

Mania,  acute,  134,  141;  puerperal,  141. 
Materia  Medica,  uses  of,  17. 
Measles,  61,  62;  sequels  of,  110. 
Medecine  expectante,  18. 
Melcena,  327. 

Meningitis,  156;  delirium  of,  139,  156;  Spinal,  168. 
£  ^Menorrhagia,  ZQfc  distinguished  from  hemorrhage,  98. 

Menstruation,  condition  of,  129;  Irregular,  382;  Painful,  382;    Profuse,  382;    in 

Pregnancy,  371 ;  Suppressed,  381 ;  distinguished  from  chlorosis,  103;  with  hse- 

matemesis,  96;  with  haemoptysis,  95;  Vicarious,  95,  96. 
Mercurial  paralysis,  178. 
Mesenteric  disease,  109;  anaemia  from,  101. 
Mesentery,  growths  in,  386. 
Metastasis  of  Erysipelas,  137;  of  Parotitis,  303;  of  Rheumatism,  107;  in  the  acute 

form,  68 ;  in  the  synovial,  69. 
Method  of  diagnosis,  25;  of  obtaining  a  history.  28;  good  and  bad  methods,  21. 
Metritis,  386. 

Mind,  unsound,  131,  141:  its  definition,  140. 
Mitral  valve,  disease  of,  290. 
Mobility,  alterations  of,  171. 
Mollities  ossium,  389. 
Molluscum,  402. 
Mouth,  disease  of,  299. 
Mumps,  303. 
Murmurs,  blood-,  104;  dependent  on  antemia,  103;  distinguished  from  valvular, 

278;  Arterial,  104;  Cardiac,  270;  Diastolic,  275;  Musical,  290;  Systolic,  275; 

Venous,  105;  Vesicular  in  respiration,  195. 
Muscae  volitantes,  144. 
Muscles,  diseases  of,  389;  abscess,  390;  atrophy,  390;  fatty  degeneration,  179,  389; 

local  paralysis,  179;  from  lead,  81;  from  over-strain,  179. 
Muscular  movements  as  a  symptom  of  brain  disease,  146. 

Nakcotic  poisoning,  77. 

Nares,  hemorrhage  from,  92 ;  simulating  haemoptysis,  93. 

Neck,  tumours  of,  116. 

Nephralgia  and  Nephritis,  362. 

Nerves,  Anatomical  relations  of,  in  neuralgia,  181;  in  paralysis,  173,  178;  Cranial, 
paralysis  of,  147,  179;  Fifth  pair,  neuralgia  of,  184;  Laryngeal,  affection  of, 
236;  in  false  croup,  237;  Paralysis  as  the  effect  of  pressure  on,  179:  Spinal, 
pain  of,  187;  F 

Nervous  system. 'general  indications  regarding,  129;  irritation,  184. 

Nervousness,  122. 

Nettle-rash,  393. 

Neuralgia,  181;  spinal,  187. 

Nodes,  syphilitic,  389. 

Nomenclature,  objectionable,  in  disease  of  lungs,  195,  215;  in  disease  of  heart,  270. 

Nose,  bleeding  from,  92  ;  polypus  of,  93. 

Nosology,  17;  new  uterine,  386. 

Notes  of  cases,  importance  of,  28,  128 ;  outline  of,  v. 

Obesity,  39;  when  not  occurring  after  mid-life,  305. 

Object  of  author,  20. 

Objective  phenomena,  2G,  35. 

Obstruction  of  bowels,  322. 

(Edema,  or  local  dropsy,  87;  caused  by  anosmia,  103;  by  diseased  glands,  118;  of 

glottis,  237;   of  Upper  half  of  body,  261. 
(Esophagus,  diseases  of,  308;  spasm,  309;  stricture,  309. 
Omentum,  diseases  of,  118;  cancer,  119;  tumours,  007. 
Opium,  poisoning  by,  77;  producing  coma,  102. 
Organs,  examination  of,  127;  Diseases  of,  see  Diseases. 
Orthopnoea,  40. 
Ovarian  dropsy,  376:  a  cause  of  enlargement,  112;  resembles  ascites,  90;  rules  for 

its  diagnosis,  378. 

27 


418  INDEX. 

i.  876;  not  inflammatory,  370;  enlargement,  .",77;  tumours,  378; 
frith  hysteria,  :'>7i'>. 

Vain,  distinguished  from  inflammation,  128;   from  neuralgia,  1S1;   Duration  of.  32; 

Indications  from,  142;  in  brain-disease,  111;  in  cancer,  120;  in  chest-disease, 

I;  in  colica Pictonum,  81 ;  in  heart-disease,  266 ;  in  hysteria,  122;  in  kidney- 

tase,  868;  in  peritonitis,  188;  in  rheumatism,  66,  70;  Influence  on  posture, 

■II:    Local,  188;    Relation  to  stiffness,  389;  Sympathetic,  188. 

Palpitation,  dyspeptic,   180;  nervous,  267;  distinguished  from  hypertrophy,  20S, 
271. 

l'al-y,  8e<  Pa  nth/sis. 

Pancreas,  cancer  of,  317;  disease  of,  347;  stools  in,  32$;  tumour  of,  117. 

dyBiB,  Associated  with  coma,  182;  with  stupor,  133;  Distinguished  from  pain 
and  stillness,  172;  Hysterical,  123;  Lead  palsy,  81,  179;  Of  the  Insane,  172, 
177:  Simulated,  172:  detected  by  gait,  178;  a  Symptom  of  brain-di-ease,  147; 
Varieties,  171;  ngit.-ms,  17*;  general,  177;  local,  174,  178;  of  bladder,  179; 
of  bowels  in  peritonitis,  332;  of  fore-arm,  179;  hemiplegia,  173;  muscular, 
17'.';    paraplegia,  175. 

Paraplegia,  175;  as  a  symptom  of  disease  of  brain,  147;  of  cord,  170. 

Parotitis,  303  ;  metastasis  of,  303. 

Pathology,  uses  of,  17. 

Patient,  general  appearance  of,  38;  general  state,  36;  habits,  32  ;  position,  40; 
posture  in  chest  disease,  190;  in  peritonitis,  41,  332;  his  theories,  314. 

Pemphigus,  899. 

Pepsine,  deficiency  of.  317. 

Perception,  faculty  of,  in  disease  of  brain,  181. 

Percussion,  194;  and  Auscultation,  198;  With  Modified  breath  and  voice-sounds  in 
Clavicular  region,  198;  dulness  absent,  200;  indistinct,  200;  marked,  199; 
resonance,  199;  in  Posterior  and  Lateral  regions,  200;  dulness  absent,  207  ; 
indistinct,  207;  marked,  206;  resonance,  207;  Summary,  211;  With  Super- 
added sounds,  215;  in  Clavicular  region,  217;  dulness  absent,  219;  indistinct, 
218;  marked,  217;  resonance,  218;  in  Posterior  and  Lateral  regions,  222:  dul- 
ness absent,  225;  indistinct,  223;  marked,  222;  resonance,  223;  Information 
limited,  194,  202;  Phenomena  simple,  19;   Theory  of,  192. 

Pericarditis,  281;  friction,  273,  281;  rheumatic,  68;  with  endocardial  bruit,  289; 
with  pleurisy,  282. 

Pericardium,  Adherent,  with  dilatation,  286;  signs  of,  268,  281;  Bruit  in,  friction, 
272. 

Periostitis,  113,  388;  syphilitic,  388. 

Peritoneum,  Abscess  of,  112,  113;  Cancer  of,  119;  Diseases  of,  330;  Fluid  in,  88; 
Inflammation  of,  330;  Morbid  growths  in,  330;  Tubercles  in,  111. 

Peritonitis,  Acute,  330;  with  enteritis,  333;  with  fever,  55,  333;  with  gastritis, 
312;  Chronic,  334;  with  ascites,  335;  dropsy  after,  91  ;  with  morbid  growths, 
335;  with  suppuration,  334;  with  tubercles,  336;  Idiopathic,  331;  Partial  or 
local,  332;  as  a  tumour,  177;  with  ulceration  of  bowels,  333;  Puerperal,  331; 
Traumatic,  330;   Simulated,  332;  Uterine,  333,  385. 

Perspiration  in  phthisis.  109;  rheumatic,  07. 

Pertussis,  201;  complications  of,  202;  place  in  classification,  233. 

Petechias,  53,  101. 

Pharynx,  diseases  of,  300. 

Phenomena,  duration  and  sequence  of,  32;  objective  and  subjective,  20,  35;  of  per- 
cussion and  auscultation,  199. 

Philosophical  view  of  auscultation,  196. 

Phlebitis,  297;  associated  with  oedema,  87,  297:  Capillary,  298  ;  with  acute  dropsy, 
87 ;  Occlusion  resulting  from,  298 ;  Suppurative,  297 ;  Theory  of  its  action  in 
causing  pyaemia,  100. 

Phlegmasia  dolens,  297  ;  rarely  ending  in  suppuration,  106. 

Phrenology.  130. 

Phthisis,  109;  acute,  109;  chronic.  110;  laryngsea,  235;  pulmonalis,  252;  Associ- 
ated with  hemoptysis,  93;  with  inflammation  of  brain,  153,  259;  with  pleurisy, 
245,258;  with  pneumonia,  241,  259;  Auscultation  of,  254;  cautions,  25  1 ;  dif- 
ficulties, 255;  the  early  stage,  202,  221  ;  phenomena  in  detail,  250;  In  Child- 
hood, 264;   Distinguished  from  bronchitis,  249,  258;    from  pneumonia,  240; 


INDEX.  419 

General  symptoms,  189;  Its  Place  in  classification,  2:12;  Resemblance  to  fever, 
110;   Symptoms  vary  in  intensity,  253.     See  Tubercles. 

Physiognomy  of  disease,  36. 

Physiology,  uses  of,  17. 

Pia  mater,  inflammation  of,  156. 

Pictonum,  colica,  80. 

Pityriasis,  396;  capitis,  396;  versicolor,  401. 

Plan  of  investigation  of  general  state,  28;  of  various  organs,  127. 

Plethora,  hemorrhage  in,  92,  95;  with  reference  to  stomach,  310. 

Pleura,  Adherent.  243;  Air  in,  245;  Effusion  of  lymph  in,  243;  of  serum,  auscul- 
tation, 206,  222;  from  Inflammation,  243;   Passive,  222,  244;   Pus  in,  21:;. 

Pleurisy,  Auscultation  in,  242;  dulness  of,  209;  friction  in,  222:  Complicated  with 
bronchitis,  243;  with  pericarditis,  282;  with  peritonitis,  332;  with  phthisis, 
244,258;  with  pneumonia,  243;  General  symptoms,  242;  Injury  a  cause  of. 
244;  Simulated  by  pleurodynia,  245. 

Pleurodynia,  245. 

Pleuro-pneumonia,  241,  243;  auscultatory  signs,  206,  222;  with  hepatitis,  340. 

Pneumonia,  auscultation  in,  237;  fine  crepitation,  217,  223;  Chronic,  241;  In 
Childhood,  263;  Complicated  with  fever,  241;  with  pleurisy,  243;  with  tuber- 
cles, 241 ;  Distinguished  from  bronchitis,  24S  ;  from  phthisis  in  upper  lobe, 
218,240;  General  symptoms,  238;  delirium,  136,  241;  hcenioptysis,  238 ;  sputa, 
191;  Pyceniic,  233;   Terminating  in  abscess,  241. 

Pneumo-thorax,  245;  Auscultation,  202,  210;  metallic  tinkling,  223:  percussion, 
214;  succussion,  223;  in  their  totality,  246;  Causes,  245,  247;  Distinguished 
from  emphysema,  246;  General  symptoms,  245. 

Poisoning,  75;  Blood-,  91;  Irritant,  90;  effects  on  the  stomach,  312;  Lead,  81;  drop- 
wrist  without,  179;  Narcotic,  77;  coma  of,  132;  Slow,  78;  painter's  colic  a 
form  of,  80. 

Polypus  of  nose,  93;  of  uterus,  384. 

Pompholyx,  399. 

Porrigo  favosa,  401 ;  decalvans,  391,  401. 

Position  of  patient,  36;  in  bed,  40,  45;  in  chest  disease,  190;  in  heart-disease,  45; 
in  paralysis,  46;  of  pain  in  peritonitis,  41,  332;  prone,  40;  in  prostration,  41; 
in  rheumatic  fever,  41. 

Posture  of  patient,  36;  bent,  46;  erect,  41;  horizontal  with  reference  to  pain  in 
head,  146;  semi-erect,  especially  in  heart-disease,  190;  expressing  pain  in  ab- 
domen, 333. 

Pregnancy,  amenorrhoea  of,  381;  character  of  abdominal  fulness  in,  379;  menstru- 
ation in,  379;  symptoms  of,  379;  tubal,  379;  urine  of,  375. 

Prolapsus  uteri,  384  ;  of  vagina  involving  bladder,  384. 

Prostate  gland,  disease  of,  97. 

Prurigo,  393;  podicis,  394;  pudendi,  394. 

Psoas  abscess,  113. 

Psoriasis,  395. 

Ptosis,  148. 

Puerperal  fever,  331;  peritonitis,  331. 

Pulsation,  abdominal,  225;  of  tumours,  118:  direction  of,  293. 

Pulse,  characters  of,  36;  Irregular,  268;  Intermitted,  268 ;  Special  indications,  43; 
in  chest-disease,  189;  in  heart-disease,  288;   Uneven,  268. 

Pupil,  action  of,  in  disease,  143. 

Purpura,  100;  with  haemoptysis,  95;  with  htematemesis,  90;  with  hsematuria,  97. 

Pus  in  abdomen,  113,  334  ;   in  blood,  106,  290  ;  in  thorax,  113,  243  :  in  urine,  3 
its  Chemical  relations,  354 ;  Microscopic  appearances,  355. 

Pyaemia,  290;  Associated  with  pneumonia,  239;  with  purpura,  100;  with  suppura- 
tive phlebitis,  106,  290  ;  Distinguished  from  gout,  73  ;  from  rheumatism,  68  ; 
Resemblance  to  glanders,  80. 

Pyelitis,  365. 

Pylorus,  stricture  of,  310;  cancerous,  311. 

Qitackert,  language  of,  in  exaggeration,  381  :  in  imagination,  384;  in  unfavoura- 
ble opinion,  221  ;  in  ulceration  of  uterus,  385  ;  Success  of,  based  on  faulty  diag- 
nosis, 24;  on  false  prognosis,  71. 

Quinsy,  301  ;  with  laryngitis,  234. 


420  INDEX. 

Rai  nma,  889. 

Rational  medicine,  21. 
turn,  scirrhus  of,  110. 

Ki'ilection,  faculty  of,  as  an  indication  of  disease,  131. 

Regions,  examination  of,  119. 

ii  of  the  chest,  Modified  sounds  in,  108;    the  clavicular,  108;  the  posterior 
"  and  Literal.  206  ;  Superadded  sounds  in,  215;  the  clavicular,  217  ;  the  posterior 
and  lateral,  222. 

Remedies,  selection  of,  28. 

Remittent  fever,  56. 

Resonance  of  Bowel  in  ascites,  80:  in  examination  of  abdomen,  306;  in  ovarian 
dropsy,  377;  in  chronic  peritonitis,  335;  in  tympanitis,  328 ;  of  Chest,  103;  ex- 
cessive, in  emphysema,  261;  in  pueunio-thorax,  240;  modifications  of,  108; 
of  Voice,  195;  segophony,  200;  in  early  consolidation,  208;  modifications  of, 
108.     See  Auscultation  and  Percussion. 

Respiration,  characters  of,  indicating  disease,  100 ;  healthy,  195 ;  modifications  of, 
198.     See  Auscultation. 

Respiratory  organs,  diseases  of,  232  ;  general  examination,  129 ;  general  symptoms, 
188;  history,  188.     See  Lungs. 

Rheumatism,  66  ;  acute,  66;  in  children,  67;  chorea  in,  125;  chronic,  70;  delirium 
in,  137  ;  fibrous,  CO  ;  gonorrhocal,  69;  muscular,  GO;  sub-acute,  08  ;  synovial,  69. 

Rheumatic  gout,  73. 

Rib,  fracture  of,  causing  pleurisy,  244. 

Rickets,  389. 

Rigor,  48. 

Ringworm  so-called,  a  lichen,  .304;. herpes,  397;  True,  favus,  401. 

Roseola,  393. 

Rupia,  400. 

Sarcina  Venteicula,  313 ;  urine  with,  350. 

Scabies,  398. 

Scalp,  tumours  of,  115. 

Scarlatina,  62  ;  albuminuria  of,  3G7  ;  dropsy  of,  87  ;  with  hematuria,  97 ;  its  pecu- 
liar tension,  39. 

Sciatica,  185  ;  a  form  of  rheumatism,  71. 

Scirrhus  of  Liver,  343;  of  Lungs,  260;  of  Pancreas,  347;  observed  as  a  tumour, 
119;  of  Rectum,  119;  of  Stomach,  311;  hjematemesis  in,  96;  its  position,  117; 
the  usual  form  of  cancer  in,  119;  of  Uterus,  386. 

Scrofula,  108. 

Scrofulous  Abscesses,  303,  405;  Enlargements,  111;  Inflammation  of  brain,  151;  de- 
lirium of,  138;  Ulcer,  404  ;  in  throat,  302. 

Scurvy,  100;  hocmatemesis  in,  06. 

Semeiology,  17;  of  the  brain,  130;  special  indications,  43. 

Sensation,  altered,  in  disease  of  brain,  142;   loss  of,  anesthesia.  171. 

Sensations  of  patient,  36,  41;  in  disease  of  chest,  190;  of  pain,  exaggerated,  122; 
mistaken  for  loss  of  power,  387;  in  disease  of  stomach,  errors  from,  314;  un- 
usual, 47.  • 

Senses,  special  affection  of,  142. 

Sensibility,  alterations  of,  142;  loss  of,  171. 

Sequence  of  phenomena,  33. 

Serum,  effusion  of,  112;  in  dropsy,  103;  in  the  pericardium,  268,  281;  in  perito- 
neum, 88;  in  pleura,  200,  244;  in  ventricles  of  brain,  132,  151. 

Sexual  organs  in  nervous  disorders,  167. 

Shingles,  397. 

Simulation  of  epilepsy,  163;  of  paralysis,  172;  of  partial  loss  of  power,  180;  espe- 
cially recogni«ed  by  the  gait,  178. 

Sight,  alterations  in,  142  ;  perversions  of,  143. 

Skin,  condition  of,  in  reference  to  general  state,  36;  Cellular  inflammation,  406; 
Difficulties  of  diagnosis  of  disease,  388;  Discolorations  of,  403;  bronzed,  404; 
ephelides,  404;  vitiligo,  404 ;  Diseases  of,  391;  acne,  300:  ecthyma,  300;  eczema, 
■  ;  erythema,  302;  favus,  401;  herpes,  307 ;  icthyosis,  305;  impetigo,  398  ; 
lepra,  305;  lichen,  303;  lupus,  404;  pemphigus,  309;  pityriasis,  396;  versi- 
color, 401 ;  pompholyx,  309;  porrigo  decalvans,  301,  401  ;  favosa,  401 ;  prurigo, 


INDEX.  421 

393;  psoriasis,  395;  roseola,  392;  rupia,  400;  scabies,  398;  scrofulous  ulcer, 
404;  strophulus,  394;  sycosis,  398;  syphilitic  eruptions,  402;  tubercle  of  skin, 
401;  uticaria,  393;  Cancrum  oris,  300,  405;  Coutagion  of  disease,  407;  Ele- 
phantiasis of  the  Arabians,  405;  of  the  Greeks,  401;  Endemial  diseases,  405; 
Symptoms  associated  with  disease  of,  407. 

Skull/fracture  of,  132. 

Smallpox,  62. 

Solids  and  fluids,  relation  of,  in  the  chest,  194. 

Sore-throat,  301;  its  importance  in  laryngitis,  232. 

Sounds,  Breath  and  Voice,  modifications  of,  19G;  and  of  percussion-resonance,  18G; 
deductions,  194;  Superadded,  195;  continuous,  210;  interrupted,  215;  their 
teaching,  230;  of  the  Heart,  270;  modifications  of  normal,  270;  morbid,  270;  of 
Percussion,  194;   of  Respiration,  195.     See  Auscultation  and  Percussion. 

Spantemia,  102. 

Spasm,  146  ;  of  asthma,  251 ;  in  disease  of  cord,  168  ;  with  paralysis,  171,  177  ;  of 
oesophagus,  309  ;  varieties,  124. 

Spectra,  ocular,  144. 

Speculum,  uses  of,  385  ;  abuse  of,  24 ;  injury  from,  385. 

Spermatorrhoea,  167. 

Spermatozoa  in  urine,  356. 

Spinal  cord,  Diseases  of,  168;  apoplexy,  177;  atrophy,  175;  chronic  disease,  169; 
inflammation,  168,176;  meningitis,  168  ;  tumoui*,  176  ;  Producing  hemiplegia, 
174;  paraplegia,  175. 

Spinal  curvature  interfering  with  auscultation,  193  ;  ia  relation  to  paralysis,  176. 

Spinal  irritation,  168,  187. 

Spinal  neuralgia,  157. 

Spine,  caries  of,  Associated  with  disease  of  cord,  168;  with  lumbar  abscess,  113; 
with  paraplegia,  175;  Distinguished  from  hysteria,  187  ;  from  rheumatism,  72. 

Spleen,  disease  of,  346 ;  enlargement,  as  a  tumour,  121 ;  hreniateniesis  from,  96 ; 
as  a  sequel  of  ague,  347. 

Spots  in  fever,  52,  100. 

Sputa,  characters  of,  190. 

Starvation  a  cause  of  antcmia,  101. 

Stethoscope,  how  applicable,  196. 

Stomach,  Dilatation  of,  313;  simulating  ascites,  313;  from  stricture  of  pylorus, 
310;  Diseases  of,  308;  Distention,  315;  Dyspepsia,  313;  Effect  of  irritant 
poisons  on,  312  ;  Faulty  secretion,  315  ;  Fermentation  and  sarcina,  313  ;  Func- 
tional disorders,  313  ;  Gout  in,  318 ;  Hemorrhage  from,  96  ;  its  characters,  312 ; 
in  scirrhus,  96;  Hyperoemia  of,  316;  Inflammation  of,  312  ;  Irritation  of,  314; 
sympathetic,  312';  Organic  diseases  of,  310;  Scirrhus,  117,  311;  the  common 
form  of  cancer  of,  119;  Stricture  of  pylorus,  310;  Theories  of  patient,  314; 
Ulceration,  311. 

Strabismus,  caused  by  paralysis,  148;  in  childhood,  180;  mode  of  determining  its 
duration,  171  ;  a  symptom  of  disease  of  brain,  147. 

Stricture  of  oesophagus,  309;  of  pylorus,  310;  of  urethra  as  a  cause  of  cystitis,  370. 

Strongylus  gigas,  84. 

Strophulus,  394. 

Struma,  108,  115. 

Strumous  diathesis  in  inflammation  of  brain,  151.     Sec  Scrofulous. 

Strychnia,  poisoning  by,  86;  convulsions  in,  125. 

Student,  advice  to,  in  auscultation  of  the  chest,  192,  195:  of  the  heart,  266;  in 
examination  of  urine,  349,  355 ;  definite  course  of  inquiry  recommended,  27, 
127;  how  to  form  a  correct  opinion,  20,  48,  205;  outline  of  clinical  notes  for, 
v.  ;  warning  against  pathognomonic  signs,  19,  198. 

Stupor,  or  partial  coma,  133. 

St.  Vitus's  dance,  124. 

Subjective  phenomena,  26,  35. 
Subsultus,  145. 

Succussion,  sound  of,  216:  in  hydro-pneumo-thorax,  247. 
Sugar  in  urine,  tests  of,  360. 

Suppuration,  115;  causing  inflammation  of  brain,  150;  in  hydatid  cyst,  341;  in 
kidney,  365;  in  liver,  341;  in  peritoneum,  334;  in  pleurisy,  243;  in  pneu- 
monia, 241  ;  rigor  of,  100  ;  resembling  ague,  64;  scrofulous,  113,  404;  secon- 
dary, 106  ;  in  veins,  causing  pyaemia,  106. 


422  INDEX. 

Byoo 

Sympathetic  affections  in  dyspepsia,  308;  pains,  183;  in  disease  of  abdomen,  303. 
ptomatology,  ■■    Si  meiology. 

S'vm  \rrangement  nf.  26;  <  'omplex  character  of,  22  ;  Duration,  32  :  General, 

86;  of  disease  of  abdomen,  804 ;  of  brain,  130;  of  chest,  188;  of  regions  and 
organs,  127;  Sequence  of,  32  ;  Special,  48;  derived  from  nrine,  847  ;  indicating 
disease  in  other  organs,  871  ;  hysterical,  falsely  referred  to  uterus,  380;  sj 
pathetic,  excited  by  dyspepsia,  300.     For  oth<r  symptoms  set    Diseases.     Sub- 
divisions of,  36;  Theory  of,  true,  20;  false,  42,  314  ;   Variations,  18. 

Synovitis,  69. 

Syphilis,  119;  congenital,  403  ;  nodes  of,  389  ;  periostitis  from,  389  ;  in  rheumatism, 
72  ;  skin  diseases  of,  402,  405;  ulceration  of  fauces  from,  302. 

System,  necessity  of,  20,  127. 

Table  of  chemical  relations  of  urine,  362  ;  of  clinical  notes,  v.  ;  of  diseases,  29  ;  of 
general  symptoms,  35 ;  of  special  indications,  43. 

Tabes  mesenterica,  109. 

Taenia,  82. 

Teething,  diarrhoea  of,  325. 

Tetanus,  124;  spasms  of,  147. 

Theory  of  disease,  17,  24;  true,  21;  false,  42;  of  patient,  314;  of  Production  of 
blood-murmurs,  104;  of  valvular  murmurs,  274,  287;  of  delation  of  ausculta- 
tion and  percussion  to  solids  and  fluids,  192;  of  Teaching  of  auscultation,  19G; 
by  modified  sounds,  211 ;  by  superadded  sounds,  230. 

Thirst,  as  a  symptom,  38. 

Thorax,  "alterations  of  form  in,  193;  of  mobility,  1 93  ;  cancer  in,  119  ;  examination 
of,  188;  fluids  and  solids  in  relation  to  auscultation,  194;  general  indications 
of  disease  in,  129;  morbid  growths  in,  110,  119;  symmetry  of,  193;  tumours 
in,  259 ;  their  auscultatory  signs,  207,  210.     See  Auscultation  and  Percussion. 

Throat,  sore,  301  ;  its  importance  in  laryngitis,  232. 

Thymus  gland  in  false  croup,  237. 

Tic-douloureux,  184. 

Tobacco,  dyspepsia  of,  302. 

Tongue,  state  of,  37;  aphtha)  and  ulceration,  300;   glossitis,  300. 

Tonsils,  enlarged,  302. 

Tracheitis,  see  Croup. 

Tracheotomy,  -when  justifiable,  237;  when  injurious,  235. 

Trades,  effects  of,  32. 

Transmission  of  disease,  hereditary,  111. 

Trichina  spiralis,  84. 

Trichocephalus  dispar,  84. 

Tubercles  in  Abdomen,  109;  in  Drain,  112;  evidence  obscure,  154;  inflammation 
resulting  from,  151;  its  delirium,  137;  in  Lungs,  109;  at  base,  257;  compli- 
cated with  pneumonia,  241;  with  bronchitis,  258:  disseminated,  258;  distin- 
guished from  pneumonia,  329;  general  indications,  252;  phenomena  of  auscul- 
tation in  the  early  stage,  201,  219;  in  the  Peritoneum,  111 ;  of  the  skin,  401. 
See  I'll  (li  is  is. 

Tubercular  diathesis,  108;  inflammation  of  brain,  151;  laryngitis,  235;  ulceration 
of  bowels,  320. 

Tuberculization  of  lung-tissue,  212. 

Tumours,  abdominal,  116,  336;  distinguished  from  aneurism,  295;  palpation  and 
percussion  of,  306;  peritonitis  from,  335;  in  Brain,  112,  175;  Cancerous,  119; 
Characters  of,  118;  Fatty.  121;  Glandular,  115;  Locality  of,  113;  in  Nock, 
115;  (Edema  from,  114;  of  Ovaries,  378;  Paralysis  from,  179;  Pulsating,  118; 
of  Scalp,  115;  Superficial,  115;  Thoracic,  116;  auscultatory  phenomena  in, 
207,  210;  characters  of,  259;  simulating  laryngitis,  261;  of  Uterus,  383. 

Tympanites,  328;  with  ascites,  92;   associations,  329. 

Typhoid  fever,  52,  56. 

Typhus,  52,  56  ;  petechia  in,  100. 

Ulceration  of  Dowels,  326;  in  fever,  55;  with  hemorrhage,  98;  of  Fauces,  302; 
of  Larynx,  235;  of  Lips,  300;  Scrofulous,  of  skin,  406  ;  of  Stomach,  811;  with 
hasmatemesis,  90  ;  of  Tongue,  300. 


INDEX.  423 

Unconsciousness,  133:  with  delirium,  134. 

Urea  in  the  blood,  134;  excess  of,  in  the  urine,  374 ;  tests  for,  361. 

Uric  acid  in  gout,  72. 

Urinary  organs,  diseases  of,  363. 

Urine,  Acidity  of,  349,  374;  Albumen  in,  3GG;  relation  to  blood  in,  SCO;  to  pus  in, 
369 ;  tests  for,  358.  See  Albuminuria.  Alkalescence,  350,  374  ;  in  relation  to 
haematuria,  98;  Analysis  of,  348;  Appearance  of,  351;  deep-coloured,  351,  352; 
opaque,  352;  transparent,  351;  Bile  in,  352;  Blood  in,  352;  Changes  produced 
by  disease  in  other  organs,  372;  by  functional  disorder,  372;  Chylous,  375; 
Excess  of  water,  372;  diuresis,  370;  General  characters,  39,  44;  Lithates,  pre- 
sence of,  372;  Oxalates,  presence  of,  374;  Phosphates,  presence  of,  373;  Se- 
diments, 352;  their  chemical  relations,  353;  phosphates.  353;  pus,  354  ;  urates, 
353;  uric  acid,  353  ;  their  microscopic  appearances,  355 ;  blood- globules,  355; 
epithelium,  355  ;  oxalate  of  lime,  356;  pus  and  mucus,  355;  spermatozoa,  356; 
triple  phosphate,  356;  tubular  casts,  356;  uric  acid,  354;  vibriones,  356;  Su- 
gar in,  371 :  tests  for,  360;  Suppression  of,  366;  Table  of  chemical  relations, 
362.  , 

Urticaria,  393. 

Uterine  examination  when  called  for,  386;  new  nosology,  errors  of,  385;  spe'cialiti', 
evils  of,  381. 

Uterus,  Cancer  of,  119,  386;  Diseases  of,  381;  amenorrhcea,  381;  congestion  and 
ulceration,  385;  displacement,  384;  dysmenorrhcea,  382;  inflammation,  885; 
leucorrhoea,  383 ;  menorrhagia,  382  ;  polypus,  384 ;  prolapsus,  384  ;  tumours, 
384;  Distended  with  fluid,  91,  378;  Hemorrhage  from,  98;  Peritonitis  connect- 
ed with,  332,  333 ;  Puerperal  inflammation,  331. 

Uvula,  elongated,  as  a  cause  of  cough,  309. 

Vagina,  cancer  of,  144  ;  discharges  from,  383. 

Vaginitis  in  children,  383. 

Valves  of  the  heart,  their  Action,  275,  287;  Disease  of,  286;  aortic,  291:  mitral, 

290;  General  indications,  2S9;  Hypertrophy  with,  289;  Murmurs  caused  by, 

273  ;  the  Pulse  in,  288. 
Valvular  lesion,  286 ;  murmurs  distinguished  from  anaemic,  278 ;  See  Murmurs. 
Varioloid  eruptions,  62. 
Vegetable  parasites,  401. 

Vegetations  in  heart  producing  apoplexy,  161. 
Veins,  Diseases  of,  296;  Occlusion  of,  298;  causing  anasarca,  87;  ascites,  92;  local 

oedema,  87;  relief  by  anastomosis,  298. 
Vertigo,  145. 

Vesicular  murmur  of  respiration,  195. 
Vicarious  hemorrhages,  95,  97;  menstruation,  96. 
Vision,  alteration  in  organs  of,  143;  perversions  of,  143. 
Voice,  Affections  of,  111;  Loss  of,  234;  Method  of  observation,  206;  Kesonance  of 

voice,  195;   modified  in  disease,  198;  cegophony,  206;  amphoric,  199;.  in  early 

phthisis,  202 ;  in  advancing  phthisis,  256  ;  in  emphysema,  250  ;  in  pleurisy,  2  12  : 

in  pneumonia,  238 ;  in  pneumo-thorax,  246  ;  rationale  of  modifications,  196.     See 

Auscultation. 
Vomica  in  lungs,  202  ;  cracked-pot  sound  from,  214. 

Vomit,  black,  96.  ,,     .     ,,,  01, 

Vomiting  in  dilatation  of  stomach,  313;  in  disease  of  brain,  155;  grumous,  oil; 

stercoraceous,  321,  323;  in  stricture  of  pylorus,  310. 

White-leg,  297;  phlebitis  in,  not  suppurative,  106. 

"Whooping-cough,  see  Hooping-cough. 

Worms,  intestinal,  83;  with  disordered  bowels,  227. 


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Collaborators  will  be  found  to  contain  a  large  number  of  the  most  distinguished  names  of  the  pro- 
fession in  every  section  of  the  United  States,  rendering  the  department  devoted  to 

ORIGINAL    COMMUNICATIONS 

full  of  varied  and  important  matter,  of  great  interest  to  all  practitioners. 

As  the  aim  of  the  Journal,  however,  is  to  combine  the  advantages  presented  by  all  the  different 
varieties  of  periodicals,  in  its 
20 


BLANCHARD    &    LEA'S    MEDICAL 


REVIEW    DEPARTMENT 

Willi*  found  extended  and  impartial  reviews  of  all  important  new  works,  presenting  subjects  of 
novelty  and  interest,  together  with  very  numerous 

BIBLIOGRAPHICAL    NOTICES, 
including  nearly  all  the  medical  publications  of  the  day,  both  in  thus  country  andGreat  Britain,  with 
a  choice  selection  of  the  more  important  ooBtinental  works      This  is  followed  by  the 

QUARTERLY  SUMMARY, 

being  a  very  full  and  complete  abstract,  methodically  arranged,  of  the 

IMPROVEMENTS  AND  DISCOVERIES  IN  THE  MEDICAL  SCIENCES. 

Thi«  department  of  the  Journal,  so  important  to  the  practising  physician,  is  the  object  of  especial 
care  on  the  part  of  the  editor.  It  is  classified  and  arranged  under  different  heads,  thus  facilitating 
the  researches  of  the  reader  in  pursuit  of  particular  subjects,  and  will  be  found  to  present  a  very 
full  and  accurate  digest  of  all  observations,  discoveries,  and  inventions  recorded  in  every  branch  of 
medical  science  The  very  extensive  arrangements  of  the  publishers  are  such  as  to  aliord  to  the 
editor  complete  materials  for  this  purpose,  as  he  not  only  regularly  receives 

ALL  THE  AMERICAN  MEDICAL  AND  SCIENTIFIC  PERIODICALS, 
but  also  twenty  or  thirty  of  the  more  important  Journals  issued  in  Great  Britain  and  on  the  Conti- 
nent  thus  enabling  him  to  present  in  a  convenient  compass  a  thorough  and  complete  abstract  of 
everything  interesting  or  important  to  the  physician  occurring  in  any  part  of  the  civilized  world. 

To  their  old  subscribers,  many  of  whom  have  been  on  their  list  lor  twenty  or  thirty  year.-,  the 
publishers  feel  that  no  promises  for  the  future  are  necessary;  but  those  who  may  desire  tor  the 
first  time  to  subscribe,  can  rest  assured  that  no  exertion  will  be  spared  to  maintain  the  Journal  in 
the  high  position  which  it  has  occupied  for  so  long  a  period. 

Bv  reference  to  the  terms  it  will  be  seen  that,  in  addition  to  this  large  amount  of  valuable  and 
practical  information  on  every  branch  of  medical  science,  the  subscriber,  by  paying  in  advance, 
becomes  entitled,  without  further  charge,  to 

THE  MEDICAL  NEWS  AND  LIBRARY, 

a  monthly  periodical  of  thirty-two  large  octavo  pages.     Its  "News  Department"  presents  the 
current  information  of  the  day,  while  the  "Library  Department"  is  devoted  to  presenting  stand- 
ard works  on  various  branches  of  medicine.     Within  a  few  years,  subscribers  have  thus  received, 
without  expense,  the  following  works  which  have  passed  through  its  columns  :— 
WATSON'S  LECTURES  ON  THE  PRACTICE  OF  PHYSIC. 
BRODIE'S  CLINICAL  LECTURES  ON  SURGERY. 

Tcmn  AND  BOWMAN'S  PHYSIOLOGICAL  ANATOMY  AND  PHYSIOLOGY  OF  MAN. 
WEST'S  LECTURES  ON  THE  DISEASES  OF  INFANCY  AND  CHILDHOOD. 
MALGAIGNE'S  OPERATIVE  SURGERY,  with  wood-cuts. 
SIMON'S  LECTURES  ON  GENERAL  PATHOLOGY. 
T5FNNETT  ON  PULMONARY  TUBERCULOSIS,  with  wood-cuts, 
WEST  ON  ULCERATION  OF  THE  OS  UTERI,  and 

BROWN  ON  THE  SURGICAL  DISEASES  OF  FEMALES,  with  wood-cuts. 
WEST  ON  DISEASES  OF  WOMEN,  Part  I. 

While  in  the  number  for  January,  1858,  is  commenced  a  new  and  highly  important  work, 

HABERSHON  ON  DISEASES  OF  THE  ALIMENTARY  CANAL. 
It  will  be  seen  that  this  treatise  covers  the  whole  ground  of  affections  of  the  Digestive  Organs. 
which  furnish  so  very  large  a  portion  of  the  daily  practice  of  the  physician.  The  author's  position 
in  Guv's  Hospital,  and  the  fact  that  the  work  has  only  just  appeared  in  London,  are  sufficient  guar- 
antee "that  it  is  up  to  the  hour,  and  presents  the  most  advanced  condition  of  this  department  of  medi- 
cal science,  while  its  thorough  practical  character  is  manifested  by  the  great  number  of  cases  on 
which  it  is' founded,  no  less  than  one  hundred  and  sixty-three  being  carefully  analyzed  in  all  their 
detail*  throughout  its  pages.  It  is  therefore  hoped  that  it  will  be  found  to  fully  maintain  the  valu- 
able practical  character  of  the  works  heretofore  presented  to  subscribers  through  this  medium. 

It  will  thus  be  seen  that  for  the  small  sum  of  FIVE  DOLLARS,  paid  in  advance,  the  subscriber 
will  obtain  a  Quarterly  and  a  Monthly  periodical, 

EMBRACING  NEARLY  SIXTEEN  HUNDRED  LARGE  OCTAVO  PAGES, 

mailed  to  any  part  of  the  United  States,  free  of  postage. 

These  very  favorable  terms  are  now  presented  by  the  publishers  with  the  view  of  removing  all 
difficulties  and  objections  to  a  full  and  extended  circulation  of  the  Medical  Journal  to  the  office  of 
every  member  of  the  profession  throughout  the  United  States.  The  rapid  extension  of  mail  facili- 
ties will  now  place  the  numbers  before  subscribers  with  a  certainty  and  dispatch  not  heretofore 
attainable ;  while  by  the  system  now  proposed,  every  subscriber  throughout  the  Union  is  placed 
upon  an  equal  footing,  at  the  very  reasonable  price  of  Five  Dollars  for  two  periodicals,  without 

further  expense. 

Those  subscribers  who  do  not  pay  in  advance  will  bear  in  mind  that  their  subscription  of  Five 
Dollars  will  entitle  them  to  the  Journal  only,  without  the  News,  and  that  they  will  be  at  the  expense 
of  their  own  postage  on  the  receipt  of  each  number.  The  advantage  of  a  remittance  when  order- 
ing the  Journal  will  thus  be  apparent. 

As  the  Medical  News  and  Library  is  in  no  case  sent  without  advance  payment,  its  subscribers 
will  always  receive  it  free  of  postage. 

Remittances  of  subscriptions  can  be  mailed  at  our  risk,  when  a  certificate  is  taken  from  the  Post- 
master that  the  money  is  duly  inclosed  and  forwarded. 

Address  BLANCHARD  &  LEA,  Philadelphia. 


AND    SCIENTIFIC    PUBLICATIONS. 


ALLEN    (J.    M.),    M.  D., 
Professor  of  Anatomy  in  the  Pennsylvania  Medical  College,  &c. 

THE  PRACTICAL  ANATOMIST;  or,  The  Student's  Guide  iu  the  Dissecting- 

ROOM.     With  266  illustrations.    In  one  handsome  royal  12mo.  volume,  of  over  600  pages,  lea- 
ther.    $2  25.     {Just  Issued.) 

In  the  arrangement  of  this  work,  the  author  has  endeavored  to  present  a  complete  and  thorough 
course  of  directions  in  a  clearer  and  more  available  form  for  practical  use,  than  has  as  yet  been 
accomplished.  The  chapters  follow  each  other  in  the  order  in  which  dissections  are  usually  con- 
ducted in  this  country,  and  as  each  region  is  taken  up,  every  detail  regarding  it  is  fully  described 
and  illustrated,  so  that  the  student  is  not  interrupled  in  his  labors,  by  the  necessity  of  referring  from 
one  portion  of  the  volume  to  another. 

From  Prof.  J.  S.  Davis,  University  of  Va. 

I  am  not  acquainted  with  any  work  that  attains  so 
fully  the  object  which  it  proposes. 

From  C.   P.  Fanner,  M.  D.,  Demonstrator,   Uni- 
versity of  Michigan. 

I  have  examined  the  work  briefly,  but  even  this 
examination  has  convinced  me  that  it  is  an  excellent 
guide  for  the  Dissector.  Its  illustrations  are  beau- 
tiful, and  more  than  I  have  seen  in  a  work  of  this 
kind.  I  shall  take  great  pleasure  in  recommending 
it  to  my  classes  as  the  text-book  of  the  dissecting- 
Toom. 


However  valuable  may  be  the  "  Dissector's 
Guides"  which  we,  of  late,  have  had  occasion  to 
notice,  we  feel  confident  that  the  work  of  Dr.  Allen 
is  superior  to  any  of  them.  We  believe  with  the 
author,  that  none  is  so  fully  illustrated  as  this,  and 
the  arrangement  of  the  work  is  such  as  to  facilitate 
the  labors  of  the  student  in  acquiring  a  thorough 
practical  knowledge  of  Anatomy.  We  most  cordi- 
ally recommend  it  to  their  attention. —  Western  Lan- 
cet, Dec.  1S56. 

We  believe  it  to  be  one  of  the  most  useful  works 
upon  the  subject  ever  written.  It  is  handsomely 
illustrated,  well  printed,  and  will  be  found  of  con- 
venient size  for  use  in  the  dissecting-room. — Med. 
Examiner,  Dec.  1S56. 


ANALYTICAL    COMPENDIUM 
OF  MEDICAL  SCIENCE,  containing  Anatomy,  Physiology,  Surgery,  Midwifery, 

Chemistry,  Materia  Medica,  Therapeutics,  and  Practice  of  Medicine.  By  John  Neill,  M.  D.. 
and  F.  G.  Smith,  M.  U.  New  and  enlarged  edition,  one  thick  volume  royal  12mo.  of  over 
1000  pages,  with  374  illustrations.     OT  See  Neill,  p.  24. 


ABEL   (F.    A.),    F.C.S.    AND    C.    L.    BLOXAM. 
HANDBOOK  OF  CHEMISTRY,  Theoretical,  Practical,  and  Technical ;  with  a 


Recommendatory  Preface  by  Dr.  Hofmann. 
pages,  with  illustrations.    $3  25. 


In  one  large  octavo  volume,  extra  cloth,  of  662 


ASHWELL    (SAMUEL),   M.D., 

Obstetric  Physician  and  Lecturer  to  Guy's  Hospital.  London. 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  PECULIAR  TO  WOMEN 

Illustrated  by  Cases  derived  from  Hospital  and  Private  Practice.  Third  American,  from  the  Third 
and  revised  London  edition.     In  one  octavo  volume,  extra  cloth,  of  528  pages.     $3  00. 


The  most  useful  practical  work  on  the  subject  in 
the  English  language.  —  Boston  Med.  and  Surg, 
Journal. 


The  most  able,  and  certainly  the  most  standard 
and  practical,  work  on  female  diseases  that  we  have 
yet  seen. — Medico-C hirurgical  Revitic. 


ARNOTT    (NEILL),  M.  D. 
ELEMENTS    OF    PHYSICS;    or  Natural  Philosophy,  General  and  Medical. 

Written  for  universal  use,  in  plain  or  non-technical  language.  A  new  edition,  by  Isaac  Hays. 
M.  D.  Complete  in  one  octavo  volume,  leather,  of  484  pages,  wi;h  about  two  hundred  illustra- 
tions.    $2  50.  

BUDD  (GEORGE),  M.  D.,  F.  R.  S., 

Professor  of  Medicine  in  King's  College,  London. 

ON   DISEASES   OF   THE   LIVER.      Third   American,  from   the   third   and 

enlarged  London  edition.     In  one  very  handsome  octavo  volume,  extra  cloth,  with  lour  beauti- 
fully colored  plates,  and  numerous  wood-cuts.     pp.  500.     $3  00.     (Now  Ready.) 
Has  fairly  established  for  itself  a  place  among  the     is  not  perceptibly  changed,  the  history  of  liver  dis- 
classical  medical   literature   of  England. — British     eases  is  made  more  complete,  and  is  kept  upon  a  level 
and  Foreign  Medico-Chir.  Review,  July,  1S57.  witli  the  progress  of  modern  science.     It  is  the  besr 

Dr.  Budd's  Treatise  on  Diseases  of  the  Liver  is     f°^  oa £**}*?*  of  th°£ive*  in,  a">'  Jffflg!?8*™ 
now  a  standard  work  in  Medical  literature,  and  dur-     London  Med.  Tones  and  Gazette,  June  2, ,  B57. 

This  work,  now  the  standard  book  of  reference  on 
the  diseases  of  which  it  treats,  has  been  carefully 
revised,  and  many  new  illustrations  of  the  views  of 
the  learned  author  added  in  the  present  edition. — 
Dublin  Quarterly  Journal,  Aug.  lfroT. 


ing  the  intervals  which  have  elapsed  between  the 
successive  editions,  the  author  has  incorporated  into 
the  text  the  most  striking  novelties  which  have  cha- 
racterized the  recent  progress  of  hepatic  physiology 
and  pathology ;  so  that  although  the  size  of  the  book 


BY  THE  SAME  AUTHOR. 

ON  THE   ORGANIC  DISEASES   AND  FUNCTIONAL  DISORDERS  OF 

THE  STOMACH.     In  one  neat  octavo  volume,  extra  cloth.     $1  50. 

From  the  high  position  occupied  by  Dr.  Budd  as  style,  the  subjects  are  well  arranged,  and  the  practi- 
a  teacher,  a  writer,  and  a  practitioner,  it  is  almost  ,  cal  precepts,  both  of  diagnosis  and  treatment,  denote 
needless  to  state  that  the  present  book  may  be  con-  '  the  character  of  a  thoughtful  and  experienced  phy- 
■ulted  with  great  advantage.  It  is  written  man  easy  I  sician.— London  Med.  Times  and  Gazette. 


I 


BLANCHARD  &  LEA'S  MEDICAL 


BROWN    (ISAAC    BAKER), 
BuTgeon-Acoonohem  to  St.  Mary's  Hospital)  Ice. 

ON  SOME  DI8EASBS  OF  WOMEN  ADMITTING  OF  SURGICAL  TREAT- 
MENT.    With  handsome  illustrations.    One  vol.  8vo.,  extra  cloth,  pp  27fl.    »i  80. 
Mr.  Brown  has  earned  for  himself  a  high  repnta-    and  merit  the  careful  attention  of  every  surgeon- 

tlon  in  the  operative  treatment  of  sundry  diseases    accoucheur. — Association  Journal. 

and  injuries  to  which  females  are  P,-rul,Mriy  sul,j,,-t  hesitation  in  recommending  this  book 

Wecan  truly  say  of  h»work  that  it  is  an  important    tothecarefu,  ttttention  ,„•  a„   Burgeons  who  make 


ition  tn  obstetrical   literature.     Thejoperative 

SUggl 


>"<>"■>"  ■•"  '""•""'      ,    ",   '  ,.,  V      female  complaints  a  part  of  their  study  and  practice, 
md  contrivances  which  Mr.  Brown  de-        ,.,,,■.  ,,'     ,  ,„,;„  ;„„,...„/ 


*Ugge8MOns  imu  cuumvau««  wim  ..  i.  i  .  uiurrii  ...  -  /,,./,/;,.  (ntarl^rlM   Inurnal 

scribes,  exhibit  much  practical  sagacity  and  skill,  .  —VuUlin  quarterly  Journal 


BENNETT   (J.    HUGHES),    M.D.,    F.  R.  S.E., 
Professor  of  Clinical  Medicine  in  the  University  of  Edinburgh,  &c. 

THE  PATHOLOGY  AND  TREATMENT  OP  PULMONARY  TUBERCU- 
LOSIS,  and  on  the  Local  Medication  of  Pharyngeal  and  Laryngeal  Diseases  frequently  mistaken 
for  or  associated  with,  Phthisis.    One  vol.  8vo.,extra  cloth,  with  wood-cuts.    pp.  130.    $1  ~'-j. 


BENNETT   (HENRY),  M.  D. 
A  PRACTICAL   TREATISE    ON  INFLAMMATION  OP  THE  UTERUS, 

ITS  CERVIX  AND  APPENDAGES,  and  on  its  connection  with  Uterine  Disease.  Fourth 
American,  from  the  third  and  revised  London  edition.  To  which  isadded  (Jul '//,  1856),  a  Review 
of  the  Present  State  OF  Uterine  Pathology.  In  one  neat  octavo  volume,  extra  cloth,  of 
500  pages,  with  wood-cuts.  $2  00  Also,  the  "Review,"  for  sale  separate.  Price  50  cents. 
The  addition  of  the  "Review"  presents  the  recent  aspects  of  the  questions  discussed  in  this 
well-known  work. 

When,  a  few  years  back,  the  first  edition  of  the 
present  work  was  published,  the  subject  was  one  al- 
most entirely  unknown  t<>  the  obstetrical  celebrities 
of  the  day  ;  and  even  now  we  have  reason  to  know 
that  the  bulk  of  the  profession  are  not  fully  alive  no 
the  importance  and  frequency  of  the  disease  of  which 
it  takes  cognizance.  The  present  edition  is  so  much 
enlarged,  altered,  and  improved,  that  it  can  scarcely 
be  considered  the  same  work. — Dr.  Ranking' s  Ab- 
stract. 


This  edition  has  been  carefully  revised  and  altered, 
and  various  additions  have  been  made,  which  render 
it  more  complete,  and,  if  possible,  more  worthy  of 
the  high  appreciation  in  which  it  is  held  by  the 
medical  profession  throughout  the  world.  A  copy 
should  be  in  the  possession  of  every  physician.— 
Charleston  Med.  Journal  and  Revitw. 

We  are  firmly  of  opinion  that  in  proportion  as  a 
knowledge  of  uterine  diseases  becomes  more  appre- 
ciated, this  work  will  be  proportionably  established 
as  a  text- book  in  the  profession. — The  Lancet. 


BIRD  (GOLDING),  A.  M.,  M.  D.,  &c. 
URINARY     DEPOSITS  :     THEIR     DIAGNOSIS,    PATHOLOGY,    AND 

THERAPEUTICAL  INDICATIONS.     A  new  and  enlarged  American,  from  a  late  improved 
London  edition.   With  over  sixty  illustrations.    In  one  royal  12mo.  vol,  extra  cloth,  pp.  372.  $130. 


It.  can  scarcely  be  necessary  for  us  to  say  anything 

of  the  merits  of  this  well-known  Treatise,  which  so 
admirably  brings  into  practical  application  the  re- 
sults of  those  microscopical  and  chemical  researches 
regarding  the  physiology  and  pathology  of  the  urr- 
nary  secretion,  which  "have  contributed  so  much  to 
the  increase  of  our  diagnostic  powers,  and  to  the 


extension  and  satisfactory  employment  of  our  thera- 
peutic resources.  In  the  preparation  of  this  new 
edition  of  his  work,  it  is  obvious  that  Dr.  Golding 
Bird  has  spared  no  pains  to  render  it  a  faithful  repre- 
sentation of  the  present  state  of  scientific  knowledge 
on  the  subject  it  embraces.—  The  British  and  Foreign 
MeUico-Chirurgical  Review. 


BY   THE   SAME   AUTHOR. 

ELEMENTS  OF  NATURAL  PHILOSOPHY;   being  an  Experimental!  Intro 

duction  to  the  Physical  Sciences.     Illustrated  with  nearly  four  hundred  wood-cuts, 
third  London  edition.     In  one  neat  volume,  royal  12mo  ,  extra  cloth,     pp.  402. 


From  the 


25. 


BOWMAN  (JOHN    E.),  M.D. 


PRACTICAL   HANDBOOK    OF    MEDICAL    CHEMISTRY.     Second  Ame- 

rican,  from  the  third  and  revised  English  Edition.    In  one  neat  volume,  royal  12mo.,  extra  cloth, 
with  numerous  illustrations,     pp.  2S8.     $1  25. 

BY  THE  SAME  AUTHOR. 

INTRODUCTION    TO    PRACTICAL    CHEMISTRY,    INCLUDING    ANA- 

LYSIS.     Second  American,  from  the  second  and  revised  London  edition.     With  numerous  illus- 
trations.   In  one  neat  vol.,  royal  12mo.,  extra  cloth,    pp.300.    $125. 


BEALE  ON  THE  LAWS  OF  HEALTH  IN  RE- 
LATION TO  MIND  AND  BODY.  A  Series  of 
Letfc  rs  from  an  old  Practitioner  to  a  Patient.  In 
one  volume,  royal  12 mo.,  extra  cloth,  pp.  296. 
80  cents. 

BUSHNAN'S  PHYSIOLOGY  OF  ANIMAL  AND 
VEGETABLE  LIFE  ;  a  Popular  Treatise  on  the 
Functions  and  Phenomena  of  Organic  Life.  In 
one  handsome  royal  )2mo.  volume,  extra  cloth, 
with  over  100  illustrations,    pp.234.    80  cents. 


BUCKLER  ON  THE  ETIOLOGY,  PATHOLOGY, 
AND  TREATMENT  OF  FIBRO-BRONCHI- 
T1S   AND    RHEUMATIC    PNEUMONIA.      In 

one  Svo.  volume,  extra  cloth,     pp.  150.     $1  25. 

BLOOD  AND  URINE  (MANUALS  ON).  BY 
JOHN  WILLIAM  GRIFFITH,  G.  OWEN 
REESE,  AND  ALFRED  MARKWICK.  One 
thick  volume,  royal  12mo.,  extra  cloth,  with 
plates,    pp.  460.     SI  25. 

BRODIE'S  CLINICAL  LECTURES  ON  SUR- 
GERY.    1  vol.  8vo.,  cloth.    350  pp.     8125. 


AND    SCIENTIFIC    PUBLICATIONS. 


BARCLAY  (A.  W.)     M.  D., 
Assistant  Physician  to  St.  George's  Hospital,  fee. 

A  MANUAL  OF  MEDICAL  DIAGNOSIS j    being  an  Analysis  of  the  Si| 

and  r^vmptonis  of  Disease.     In  one  neat  octavo  volume,  extra  cloth,  of  424  pages.    (JSow  Ready.) 

92  ou: 

Of  works  exclusively  devoted  to  this  important    has  not  exceeded  his  powers.     We  have  thus  gi. 
branch,  our  profession  has  at  command,  coinpara-    a  specimen  of  Barclay's  generalizing  spirit  in 
tively,  but  few,  and,  therefore,  in  the  publication  of    direction;  but  the  game  pervades  his  whole  work, 
the  present  work.  Messrs.  Blanchard  &    I.  and  will,  we  are  sure,  induce  teachers  to  recommend 

conferred  a  great  favor  upon  us.    Dr.  Barclay,  from    it  strong!)  to  their  pupils.    It  is  impossible  for  us 
having  occupied,  for  a  long  period,  the  position  of    here  to  follow  the  book  into  its  particulars;  and, in- 
Medical   Registrar  at  St.  George's  Hospital,  pos-    deed,  we  think  it  enough  to  indicate,  as  we  ha 
sessed  advantages  for  correct  observation  and  reli-     the  importance  of  the  teaching  which  it  offers  to  the 
able  conclusions,  as  to  the  significance  of  symptoms,    rising  generation  of  medicine,  10  insure  for  it  a  I  earl 
which  have  fallen  to   the  lot  of  but  few,  either  in     reception  at  the  hands  of  the  profession.     It  is  the 
ivs  own  or  any  other  country.     He  has  carefully    work  of  a  physician  and  a  gentleman. — British  Med. 
systematized  the  results  of  his  observation  of  ovi  r    Journal,  Dec.  5,  \i 

twelve  thousand  patients,  and  by  his  diligence  and        ^Ve  hope  the  volume  will  have  an  extensive  fir- 
judicious    classification,   the    profession   has   been    euiation,  not  among  students  of  medicine  only,  but 
presented  with  the  most   convenient  and   reliable    practi  turners  also.     Thev  will  never  regret  a  faith  - 
work  on  the  subject  of  Diagnosis  that  it  has  been    fuj  Btm|y  of  its  pages.—  Cincinnati  Eancet  Mar. 
our  good  fortune  ever  to  examine;   we  can,  there-         „,  .    „  ,     ,  ._    ,.      ,  ...  .  .. 

fore? say  of  Dr.  Barclay's  work,  that,  from  his  svs-        This  Manual  <!  Mfdual  D  .the 

tematic  manner  of  arrangement,  his  work  is  one  of  most  scienti6c,  useful,  and  instructive  works  of  its 
the  best  works  "  for  reference"  in  the  daily  emer-  kind  ""lt  we  have  ever  read,  and  Dr.  Barclaybas 
gencies  of  the  practitioner,  with  which  we  aie  ac-  J""e  g°°d  eerviee  to  medical  science  in  collecting, 
qnainted:  but,  at  the  same  time,  we  would  recom-  arranging,  and  analyzing  the  signs  and  symptoms 
mend  our  readers,  especially  the  younger  ones,  to    of  so  many  diseases.    It  an,  cost  him  great 

read  thoroughly  and  study  diligently  the  whole  work,    labor,  and  the  profession  should  show  the]  r  appre 
and  the  •■  emergencies''  will  not  occur  so  often.-    eiation  oi   it  by  their  desire  to  procure  and  apply  its 
Southern  Med.  ant  Surg.  Jour,,.,  March,  1-  valuable  hints  and  suggestions  to  the  thousand  ob- 

"  scure  cases  which   perplex  and   balile   the    unaided 

To  give  this  information,  to  supply  this  admitted     efforts  of  any  one  man,  be  he  ever  so  wise,  and  his 
deficiency,  is  the  object  of  Dr.  Barclay's  .Manual,    opportunities  ever  so  good.    Another  most  valu 
The  task  of  composing  such  a  Work  is  neither  an     feature  in  the  work  is   that  it  has  been   furnit 
easy  nor  a  light  one  ;  but  Dr.  Barclay  has  performed    with  a  copious  index,  which  increases   its  utility 
it  in  a  manner  which  meets  our  most  unqualified    very  much  as  a  volume  ol   reference. — N.  J. 
approbation.     He  is  no  mere  theorist;  he  knows  his    and  Surg.  Reporter,  March,  1853. 
work  thoroughly,  and  in  attempting  to  perform  it,  i 


BARLOW   (GEORGE  H.),    M.D. 
Physician  to  Guy's  Hospital,  London,  &c. 

A  MANUAL  OF  THE  PRACTICE  OF  MEDICINE.     With  Additions  by  D- 

F.  Condie,  M.  D.,  author  of"  A  Practical  Treatise  on  Diseases  of  Children,"  &c.  In  one  hand- 
some octavo  volume,  leather,  of  over  bOO  pages.  (.A  new  work,  just  issued,  1856.)  ii  75. 
We  recommend  Dr.  Barlow's  Manual  in  the  warm-  will  be  found  hardly  less  useful  to  the  experienced 
est  manner  as  a  most  valuable  vade-mecum.  We  physician.  The  American  editor  has  added  to  the 
have  had  frequent  occasion  to  consult  it,  and  have  work  three  chapters — on  Cholera  Infantum,  Yellow 
found  it  clear,  concise,  practical,  aud  sound.  It  is  Fever,  and  Cerebro-spinal  Meningit:s.  These  addi- 
eminently  a  practical  work,  containing  all  that  is  tions,  the  two  first  of  which  are  indispensable 
essential,  and  avoiding  useless  theoretical  discus-  work  on  practice  destined  for  the  profession  in  this 
sion.  The  work  supplies  what  has  been  for  some  j  country,  are  executed  with  great  judgment  and  fi- 
time  wanting,  a  manual  of  practice  based  uoon  mo-  delitv-  by  Dr.  Condie,  who  has  also  succeeded  hap- 
deru  discoveries  in  pathology  and  rational  views  of  pily  in  imitating  the  conciseness  and  clearness  of 
treatment,  of  disease.  It  is  especially  intended  fori  style  which  are  such  agreeable  characteristics  of 
the  use  of  students  and  junior  practitioners,  but  it  I  the  original  book.— Boston  Med.  and  Surg.  Journal. 


BARTLETT  (ELISHA),  M .  D. 
THE   HISTORY,  DIAGNOSIS,  AND  TREATMENT  OF  THE   FEVERS 

OF  THE  UNITED  STATES.     A  new  and  revised  edition.     By  Aloxzo  Clark.  M.  D  ,  Prof. 

of  Pathology  and  Practical  Medicine  in  the  N.  Y.  College  of  Physicians  and   Surgeons,  fee.     In 

one  octavo^volume,  of  six  hundred  pages,  extra  cloth.  (Now  Ready.)   Price  S3  OU. 

It  is  the  best  work  on  fevers  which  has  emanated    logy.     His  annotations  add  much  to  the  interest  of 
from  the  American  press,  and  the  present  editor  has    the  work,  and  have  brought  it  well  up  to  the  eondi- 
carefully  availed  himself  of  all  information  exist-     tion  of  the  science  as  it  exists  at  the  present  day 
in°-  upon  the  subject  in  the  Old  and  New  World,  so    in  regard  to  this  class  of  diseases.— South*  m  . 
that  the  doctrines  advanced  are  brought  down  to  the    and  Surg.  Journal,  Mar.  1S57. 

latest  date  in  the  progress  of  this  department  of  it  is  a  work  of- great  practical  value  and  interest. 
Medical  Science. — London  Mid.  Times  andGazetle,  containing  much  that  is  new  relative  to  the  several 
May  -2,  1557.  diseases  of  which  it  treats,  and,  with  the  additions 

This  excellent  monograph  on  febrile  disease,  has  of  the  editor,  is  fully  up  to  the  times.  The  distinct- 
stood  deservedly  high  since  its  first  publication.  It  ive  features  of  the  different  forms  ol  fever  are  plainly 
will  be  seen  that  it  has  now  reached  its  fourth  edi-  and  forcibly  portrayed,  and  the  lines  of  uemarca 
tion  under  the  supervision  of  Prof.  A.  Clark,  a  gen-  carefully  and  accurately  drawn,  and  to  the  An 
tleman  who,  from  the  nature  of  his  studies  and  pur-  can  practitioner  is  a  more  valuable  and  safe  guide 
suits,  is  well  calculated  to  appreciate  and  discuss  than  any  work  on  fever  extant.— OAto  Med.  and 
the  many  intricate  and  difficult  questions  in  patho-     Surg.  Journal,  May,  1--j.. 

CURLING    (T.    B.),    F.  R.S., 
Surgeon  to  the  London  Hospital,  President  of  the  Hunterian  Society,  &c. 

A  PRACTICAL  TREATISE  ON  DISEASES  OF  THE  TESTIS,  SPERMA- 
TIC CORD,  AND  SCROTUM.  Second  American,  from  the  second  and  enlarged  trehsh  edi- 
tion. In  one  handsome  octavo  volume,  extra  clolh,  with  numerous  illustrations,  pp.  420.  {Just 
Issued,  1856.)    $2  00. 


BLANCHARD  &  LEA'S  MEDICAL 


CARPENTER  (WILLIAM    B.),   M.D.,  F.  R.  S.,  &c, 
Examiner  in  Physiology  and  Comparative  Anatomy  in  the  University  of  London. 

PRINCIPLE8  OF  III  MAN  PHYSIOLOGY;  with  their  chief  applications  to 
Psychology)  Pathology,  Therapeutics,  Hygiene,  and  Forensic  Medicine.  A  new  American,  from 
the  lasl  and  revised  London  edition.  With  neai  ly  three  hundred  illustrations.  Edited,  with  addi- 
tions, by  Frahcib  <  >i  bnky  Smith,  M.  D.,  Professor  of  the  Institutes  of  Medicine  in  the  Pennsyl- 
vania Medical  College,  Bee  In  one  very  large  and  beautiful  octavo  volume, of  about  nine  hundred 
lartre  pages,  handsomely  printed  and  strongly  hound  in  leather,  with  raised  bands.  (Just  Issued, 
1856.)    | 

In  the  preparation  of  this  new  edition,  the  author  has  spared  no  labor  to  render  it,  as  heretofore. 
a  complete  and  lucid  exposition  of  the  most  advanced  condition  of  its  important  subject.  The 
amount  ol  the  additions  required  to  effect  this  object  thoroughly,  joined  to  the  former  large  size  ol 

the  vol e,  presenting  objections  arising  from  the  unwieldy  hulk  of  the  work,  he  has  omitted  all 

those  portions  not  bearing  directly  upon  Human  Physiology,  designing  to  incorporate  them  in 
his  forthcoming  Treatise  on  General  Physiology.  As  a  lull  and  accurate  text-book  on  the  Phy- 
siology ol  -Man,  the  work  in  its  present  condition  therefore  presents  even  greater  claims  upon 
the  student  and  physician  than  those  which  have  heretofore  won  for  it  the  very  wide  and  distin- 
guished favor  which  it  has  so  long  enjoyed.  The  additions  of  Prof.  Smith  will  he  found  to  supply 
whatever  may  have  been  wanting  to  the  American  student,  while  the  introduction  of  many  new 
illustrations,  and  the  most  careful  mechanical  execution,  render  the  volume  one  of  the  most  at- 
tractive as  yet  issued. 

For  upwards  of  thirteen   years  Dr.  Carpenter's1  To  eulogize  this  great  work  would  be  superfluous 

work  has   been  considered  by  the  profession  gene-  We  should  observe,  however,  that  in  this  edition 

rally,  both  in  tliis  country  and  England,  as  the  most  the  author   has  remodelled  a  large   portion  of  the 

valuable  compendium  on  the  subject  of  physiology  former,  and  the  editor  has  added  much  matter  of  in- 

111  our  language.    This  distinction  it  owes  to  the  high  terest,  especially  in  the  form  of  illustrations.     We 

attainments  and  unwearied  industry  of  its  accom-  may  confidently  recommend  it,  as  the  most  complete 

f dished  author.     The  present  edition  (which,  like  the  work   on    Human    Physiology  in   our    language. — 

ast  American  one,  was  prepared  by  the  author  him-  Southern  Med.  and  Surg.  Journal,  December,  1&55. 

self),  is  the  result  of  such  extensive  revision   that  it  The  mogt  complete  work  <)n  the  BCience  in  our 

may  almost  be  consideredanew  work.    We  need  language.— .Ajm.  Med.  Journal. 


hardly  say,  in  concluding  this  brief  notice,  that  while 
the  work  is  indispensable  to  every  student  of  medi- 
cine in  this  country,  it  will  amply  repay  the  practi- 
tioner for  its  perusal  by  the  interest  and  value  of  its 
contents. — Boston  Med.  and  Surg.  Journal. 

This  is  a  standard  work — the  text-book  used  by  all 
medical  students  who  read  the  English  language. 
It  has  passed  through  several  editions  in  order  to 


The  most  complete  work  now  extant  in  our  lan- 
guage.— N.  O.  Med.  Register. 

The  best  text-book  in  the  language  on   this  ex- 
tensive subject. — London  Med.  Times. 

A  complete  cyclopaedia  of  this  branch  of  science. 
—N.  Y.  Med.  Times. 

The  profession  of  this  country,  and  perhaps  also 
keep  pace  with  the  fapidly  growing  science  of  Phy-  of  Europe,  have  anxiously  and  for  some  time  awaited 
siology.  Nothing  need  be  said  in  its  praise,  for  its  ,  the  announcement  of  this  new  edition  of  Carpenter's 
merits  are  universally  known;  we  have  nothing  to:  Human  Physiology.  H4s  former  editions  have  for 
say  of  its  defects,  for  they  only  appear  where  the  ;  many  years  been  almost  the  only  text-book  on  Phy- 


siology in  all  our  medical  schools,  and  its  circula- 
tion among  the  profession  has  been  unsurpassed  by 
any  work  "in  any  department  of  medical  science. 

It  is  quite  unnecessary  for  us  to   speak   of  this 
work  as  its   merits  would   justify.     The  mere  an- 
nouncement of  itsappearance  will  afford  the  highest 
The  greatest,  the  most  reliable,  and  the  best  book  '  pleasure  to  every  student  of  Physiology,  while  its 
on  the  subject  which  we  know  of  in  the  English    perusal   will   be  of   infinite    service  in    advancing 
language. — Stethoscope.  j  physiological  science. — Ohio  Med.  and  Surg.  Journ. 


science  of  which  it  treats  is  incomplete. —  Western 
Lancet. 

The  most  complete  exposition  of  physiology  which 
any  language  can  at  present  give. — Brit,  and  For. 
Mtd.-Chiritrg.  Review. 


by  the  same  author.     (Lately  Issued.) 

PRINCIPLES  OF  COMPARATIVE   PHYSIOLOGY.     New  American,  from 

the  Fourth  and  Revised  London  edition.     In  one  large  and  handsome  octavo  volume,  with  over 
three  hundred  beautiful  illustrations,     pp.  7.rr2.     Extra  cloth,  $4  80;  leather,  raised  bands,  $5  25. 

The  delay  which  has  existed  in  the  appearance  of  this  work  has  been  caused  by  the  very  thorough 
revision  and  remodelling  which  it  has  undergone  at  the  hands  of  the  author,  and  the  large  number 
of  new  illustrations  which  have  been  prepared  for  it.  It  will,  therefore,  be  found  almost  a  new 
work,  and  fully  up  to  the  day  in  every  department  of  the  subject,  rendering  it  a  reliable  text-book 
for  all  students  engaged  in  this  branch  of  science.  Every  effort  has  been  made  to  render  its  typo- 
graphical finish  and  mechanical  execution  worthy  of  its  exalted  reputation,  and  creditable  to  the 
mechanical  arts  of  this  country. 


This  book  should  not  only  be  read  but  thoroughly 
studied  by  every  member  of  the  profession.  None 
are  too  wise  or  old,  to  be  benefited  thereby.  But 
especially  to  the  younger  class  would  we  cordially 
commend  it  as  best  fitted  of  any  work  in  the  English 
language  to  qualify  them  for  the  reception  and  com- 
prehension of  those  truths  which  are  daily  being  de- 
veloped in  physiology. — Medical  Counsellor. 

Without  pretending  to  it,  it  is  an  encyclopedia  of 
the  Bubjeet,  accurate  and  complete  in  all  respects — 
a  truthful  reflection  of  the  advanced  state  at  which 
the  science  has  now  arrived. — Dublin  Quarterly 
Journal  of  Medical  Science. 

A  truly  magnificent  work — in  itself  a  perfect  phy- 
siological study. — Ranking's  Abstract. 

This  work  stands  without  its  fellow.  It  is  one 
few  men  in  Europe  could  have  undertaken ;  it  is  one 


no  man,  we  believe,  could  have  brought  to  so  suc- 
cessful an  issue  as  Dr.  Carpenter.  It  required  for 
its  production  a  physiologist  at  once  deeply  read  in 
the  labors  of  others,  capable  of  taking  a  general, 
critical,  and  unprejudiced  view  of  those  labors,  and 
of  combining  the  varied,  heterogeneous  materials  at 
his  disposal,  so  as  to  form  an  harmonious  whole. 
We  feel  that  this  abstract  can  give  the  reader  a  very 
imperfect  idea  of  the  fulness  of  this  work,  and  no 
idea  of  its  unity,  of  the  admirable  manner  in  which 
material  has  been  brought,  from  the  most  various 
sources,  to  conduce  to  its  completeness,  of  the  lucid- 
ity of  the  reasoning  it  contains,  or  of  the  clearness 
of  language  in  which  the  whole  is  clothed.  Not  the 
profession  only,  but  the  scientific  world  at  large, 
must  feel  deeply  indebted  to  Dr.  Carpenter  for  this 
great  work.  It  must,  indeed,  add  largely  even  to 
his  high  reputation. — Medical  Times. 


AND    SCIENTIFIC    PUBLICATIONS. 


CARPENTER  (WILLIAM   BJ,   M.  D.,  F.  R.  S., 

Examiner  in  Physiology  and  Comparative  Anatomy  in  the  University  of  London. 

{Just  Issued,  1856.) 

THE  MICROSCOPE  AND  ITS  REVELATIONS.      With  an  Appendix  con- 

taming  the  Applications  of  the  Microscope  to  Clinical  Medicine,  ece.     By  F.  G.  Smith    M   D 

Illustrated  by  lour  hundred  and  thirty-four  beautiful  engravings  on  wood.     In  one  large  and  v'err 

handsome  octavo  volume,  of  724  pages,  extra  cloth,  S4  00  ;  leather,  $4  50. 

Dr.  Carpenter's  position  as  a  microscopic  and  physiologist,  and  his  great  experience  as  a  teacher 
eminently  qualify  htm  to  produce  what  has  long  been  wanted-a  good  text-book  on  !he  practical 
use  of  the  microscope  In  the  present  volume  his  object  has  been,  as  staled  in  his  Preface  «  to 
combine,  within  a  moderate  compass,  that  information  with  regard  lo  the  use  of  his  <  t0oN  '  which 
is  most  essential  to  the  working  microscopist,  with  such  an  account  of  the  objects  be<*  fitted  for 
nis  study,  as  might  qualify  him  to  comprehend  what  he  observes,  and  might  thus  prepare  him  to 
benefit  science,  whilst  expanding  and  refreshing  his  own  mind  "  That  he  has  succeeded  in  accom- 
plishing this,  no  one  acquainted  with  his  previous  labors  can  doubt. 

The  great  importance  of  the  microscope  as  a  means  of  diagnosis,  and  the  number  of  microseo- 
pists  who  are  also  physicians,  have  induced  the  American  publishers,  with  the  author's  approval  to 
add  an  Appendix,  carefully  prepared  by  Professor  Smith,  on  the  applications  of  the  instrument  to 
clinical  medicine,  together  with  an  account  of  American  Microscopes,  their  modifications  and 
accessories.  This  portion  of  the  work  is  illustrated  with  nearly  one  hundred  wood-cuts  and  it  is 
hoped,  will  adapt  the  volume  more  particularly  to  the  use  of  the  American  student 

Every  care  has  been  taken  in  the  mechanical  execution  of  the  work,  which  is  confidently  pre 
sented  as  in  no  respect  inferior  to  the  choicest  productions  of  the  London  press.  " 

The  mode  in  which  the  author  has  executed  his  intentions  may  be  gathered  from  the  following 
condensed  synopsis  of  the  '  s 

CONTENTS. 

Introduction— History  of  the  Microscope.      Chap.  I.   Optical   Principles  of  the  Microscope 
Chap.  II.    Construction  of   the  Microscope.      Chap.  III.    Accessory  Apparatus      Cmp     fV 
Management  of  the  Microscope      Chap.  V.  Preparation,  Mounting,  and  Collection  of  Objects' 
Chap.  VI.  Microscopic  Forms  of  Vegetable  Life— Protophytes.     Chap.  VII.  Higher  CrvDto°-a' 
mia.     Chap.  VIII.  Phanerogamic  Plants.     Chap.  IX.  Microscopic  Forms  of  Animal  Life—Pro 
tozoa— Animalcules.     Chap.  X.  Foraminifera,  Polycystina,  and  Sponges.     Chap.  XI   Zoophvtes 
Chap.  XII.   Echinodermata.     Chap.  XIII.   Polyzoa   and  Compound   Tunicata      Chap    XIV* 
Molluscous  Animals  Generally.     Chap.  XV.  Annulosa.     Chap.  XVI.  Crustacea      Chap'xViV 
Insects  and  Arachnida.     Chap.  XVIII.  Vertebrated  Animals.     Chap.  XIX.  Applications  of  the 
Microscope  to  Geology.     Chap.  XX.  Inorgauic  or  Mineral  Kingdom— Polarization.     Appendix 
Microscope  as  a  means  of  Diagnosis— Injections— Microscopes  of  American  Manufacture. 

Those  who  are  acquainted  with  Dr.  Carpenter's  medical  work,  the  additions  bv  Prof  Smith  srive  it 
previous  writings  on  Animal  and  Vegetable  Physio-  ;  a  positive  claim  upon  the  profession,  for  which  we 
logy,  will  tully  understand  how  vast  a  store  of  know-  doubt  not  he  will  receive  their  sincere  thanks  In 
ledge  he  is  able  to  bring  to  bear  upon  so  comprehen-  deed,  we  know  not  where  the  student  of  medicine 
sive  a  subject  as  the  revelations  of  the  microscope  ;  will  find  such  a  complete  and  satisfactory  collection 
and  even  those  who  have  no  previous  acquaintance  of  microscopic  facts  bearing  upon  phyaioloev  and 
with  the  construction  or  uses  of  this  instrument,  ;  practical  medicine  as  is  contained  in  Prof  Smith's 
Will  find  abundance  of  information  conveyed  in  clear  [  appendix;  and  this  of  itself,  it  seems  to  us  is  fullv 
and   simple  language.— Med.    Times  and   Gazette.  |  worth  the  cost  of  the  volume.— Louisville  'Medical 

Although   originally  not  intended   as   a   strictly  |  Review,  Nov.  1S56. 

BY   THE  SAME   AUTHOR. 

ELEMENTS  (OR  MANUAL)  OF  PHYSIOLOGY,  INCLUDING  PHYSIO- 
LOGICAL ANATOMY.  Second  American,  from  a  new  and  revised  London  edition.  With 
one  hundred  and  ninety  illustrations.     In  one  very  handsome  octavo  volume,  leather,     pp.  566. 

In  publishing  the  first  edition  of  this  work,  its  title  was  altered  from  that  of  the  London  volume 
by  the  substitution  of  the  word  "  Elements"  for  that  of  "  Manual,"  and  with  the  author's  sanction 
the  title  of  "Elements"  is  still  retained  as  being  more  expressive  of  the  scope  of  the  treatise. 

To  say  that  it  is  the  best  manual  of  Physiology  i      Those  who  have  occasion  for  an  elementary  trea 


now  before  the  public,  would  not  do  sufficient  justice 
to  the  author. — Buffalo  Medical  Journal. 

In  his  former  works  it  would  seem  that  he  had 
exhausted  the  subject  of  Physiology.  In  the  present, 
he  gives  the  essence,  as  it  were,  of  the  whole. — N.  Y. 
Journal  of  Medicine. 


tise  on  Physiology,  cannot  do  better  than  to  possess 

themselves  of  the  manual  of  Dr.  Carpenter. Medical 

Examiner. 

The  best  and  most  complete  expose1  of  modern 
Physiology,  in  one  volume,  extant  in  the  English 
language. — St.  Louis  Medical  Journal. 


BY  THE  SAME  AUTHOR.     (Preparing.) 

PRINCIPLES  OF   GENERAL   PHYSIOLOGY,    INCLUDING   ORGANIC 

CHEMISTRY  AND   HISTOLOGY.     With  a  General  Sketch  of   the  Vegetable  and  Animal 
Kingdom.     In  one  large  and  very  handsome  octavo  volume,  with  several  hundred  illustrations. 
The  subject  of  general  physiology  having  been  omitted  in  the  last  editions  oi  the  author's  "  Com- 
parative Physiology"  and  "Human  Physiology,"  he  has  undertaken  to  prepare  a  volume  which 
shall  present  it  more  thoroughly  and  fully  than  has  yet  been  attempted,  and  which  may  be  regarded 
as  an  introduction  to  his  other  works. 

BY   THE   SAME   AUTHOR. 

A  PRIZE  ESSAY  ON  THE  USE  OF  ALCOHOLIC  LIQUORS  IN  HEALTH 

AND  DISEASE.     New  edition,  with  a  Preface  by  D.  F.  Conpie,  M.  D.,  and  explanations  of 
scientific  words.    In  one  neat  12mo.  volume,  extra  cloth,    pp.  178.    50  cents. 


c 


BLANCHARD  &  LEA'S  MEDICAL 


CONDIE  (D.  F.),   M.  D.,  &.C. 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  CHILDREN.    Fourth 

edition,  revised  and  augmented.    In  one  large  volume,  8vo.,  leather,  of  nearly  750  pages.  $3  00. 

From  the  Author's  Preface. 

The  demand  for  another  edition  has  afforded  the  author  an  opportunity  of  again  subjecting  the 
entire  treatise  to  a  careful  revision,  and  of  incorporating  in  it  every  important  observation  recorded 
s  ince  i  be  appearance  ol  the  last  edition,  in  relerence  to  the  pathology  and  therapeutics  of  the  several 

c  -o-  ol  W  inch  it  treats. 

iii  the  preparation  of  the  present  edition,  as  in  those  which  have  preceded,  while  the  author  has 
appropriated  to  his  use  every  important  fact  that  he  has  found  recorded  in  the  works  of  others, 
having  a  direct  bearing  upon  either  oi  the  subjects  of  which  he  treats,  and  the  numerous  valuable 
observations — pathological  as  well  as  practical — dispersed  throughout  the  pages  of  the  medical 
journi  Is  "i  Europe  and  America,  he  has,  nevertheless,  relied  chiefly  upon  his  own  observations  and 
experience,  acquired  during  a  long  and  somewhat  extensive  practice,  and  under  circumstances  pe- 
culiarly well  adapted  for  the  clinical  study  of  the  diseases  of  early  life. 

Every  species  of  hypothetical  reasoning  has.  as  much  as  possible,  been  avoided.  The  author  lias 
endeavored  throughout  the  work  to  confine  himself  to  a  simple  statement  of  well-ascertained  patho- 
logical  lads,  and  plain  therapeutical  directions — his  chief  desire  being  to  render  it  what  its  title 

its  it  to  be,  A  PRACTICAL  TREATISE  OX  THE  DISEASES  OF  CHILDREN. 

Dr.  Condie's  scholarship,  acumen,  industry,  and 
practical  sense  are  manifested  in  this,  as  in  all  his 
numerous  contributions  to  science. — Dr.  Holmes's 
H'j'ort  to  the  American  Medical  Association. 

Taken  as  a  whole,  in  our  judgment,  Dr.  Condie's 
Treatise  is  the  one  from  the  perusal  of  which  the 
practitioner  in  this  Country  will  rise  with  the  great- 
est satisfaction. — Western  Journal  of  Medicine  and 


Surgery. 

One  of  the  best  works  upon  the  Diseases  of  Chil- 
dren in  the  English  language. — Western  Lancet. 

Perhaps  the  most,  full  and  complete  work  now  be- 
fore i  lie  profession  of  the  United  States;  indeed,  we 
may  say  in  the  English  language,  ft.  is  vastly  supe- 
rior to  most  of  its  predecessors. — Transylvania  Med. 
Journal. 


We  feel  assured  from  actual  experience  that  no 
physician's  library  can  be  complete  without  a  copy 
of  this  work. — N.  Y.  Journal  of  Medicine. 

A  veritable  psedintric  encyclopaedia,  and  an  honor 
to  American  medical  literature. — Ohio  Medical  and 
Surgical  Journal. 

We  feel  persuaded  that  the  American  medical  pro- 
fession will  soon  regard  it  not  only  as  a  very  good, 
but  as  the  vkry  best  "Practical  Treatise  on  the 
Diseases  of  Children." — American  Medical  Journal . 

We  pronounced  the  first  edition  to  be  the  best 
work  on  the  diseases  of  children  in  the  English 
language,  and,  notwithstanding  all  that  has  oeen 
published,  we  still  regard  it  in  that  light. — Medical 
Examiner. 


CHRISTISON  (ROBERT),  M.  D.,  V.  P.  R.  S.  E.3  &c. 
A  DISPENSATORY;  or,  Commentary  on  the  Pharmacopoeias  of  Great  Britain 

and  the  United  States  comprising  the  Natural  History,  Description,  Chemistry,  Pharmacy,  Ac- 
tions, Uses,  and  Doses  of  the  Articles  of  the  Materia  Medica.  Second  edition,  revised  and  im- 
proved, with  a  Supplement  containing  the  most  important  New  Remedies.  With  copious  Addi- 
tions, and  two  hundred  and  thirteen  large  wood-engravings.  By  R.  Eglesfeld  Griffith,  M.  D. 
In  one  very  large  and  handsome  octavo  volume,  leather,  raised  bands,  of  over  1000  pages.  $3  50. 


It  is  not  needful  that  we  should  compare  it  with 
the  other  pharmacopoeias  extant,  which  enjoy  and 
merit  the  confidence  of  the  profession  :  it  is  enough 
to  say  that  it  appears  to  us  as  perfect  as  a  Dispensa- 
tory, in  the  present  state  of  pharmaceutical  science, 
could  be  made.    If  it  omits  any  details  pertaining  to 


this  branch  of  knowledge  which  the  student,  has  a 
right  to  expect  in  such  a  work,  we  confess  the  omis- 
sion has  escaped  our  scrutiny.  We  cordially  recom- 
mend this  work  to  such  of  our  readers  as  are  in  need 
of  a  Dispensatory.  They  cannot  make  choice  of  a 
better. — Western  Journ.  of  Medicine  and  Surgery. 


COOPER  (BRANSBY   B.),  F.  R.  S. 
LECTURES  ON  THE   PRINCIPLES   AND   PRACTICE   OF   SURGERY. 

In  one  very  large  octavo  volume,  extra  cloth,  of  750  pages.    $3  00. 


COOPER  ON  DISLOCATIONS  AND  FRAC- 
TURES OF  THE  JOINTS  —Edited  by  Bransby 
B.  Cooper,  F.R.S.,  &c.  With  additional  Ob- 
servations by  Prof.  J.  C.  Warren.  A  new  Ame- 
rican edition.  In  one  handsome  octavo  volume, 
extra  eloih,  of  about  500  pages,  with  numerous 
illustrations  on  wood.    $3  25. 

COOPER  ON  THE  ANATOMY  AND  DISEASES 
OF  THE  BREAST,  with  twenty-five  Miscellane- 
ous and  Surgical  Papers.  One  large  volume,  im- 
perial Svo.,  extra  cloth,  with  252  figures,  on  36 
plates.     S2  50. 

COOPER  ON  THE  STRUCTURE  AND  DfS- 
EASES  OF  THE  TESTIS,  AND  ON  THE 
THYMUS  GLAND.  One  vol.  imperial  Svo.,  ex- 
tra cloth,  with  177  tigures  on  29  plates.     ©2  00. 


COPLAND  ON  THE  CAUSES,  NATURE,  AND 
TREATMENT  OF  PALSY  AND  APOPLEXY. 

In  one  volume,  royal  12mo.,  extra  cloth,   pp.  326. 
80  cents. 

CLYMER  ON  FEVERS;  THEIR  DIAGNOSIS, 
PATHOLOGY,  AND  TREATMENT  In  one 
octavo  volume,  leather,  of  600  pages.     $1  50. 

COLOMBAT  DE  L'ISERE  ON  THE  DISEASES 
OF  FEMALES,  and  on  the  special  Hygiene  of 
their  Sex.  Translated,  with  many  Notes  and  Ad- 
ditions, by  C.  D.  Meigs,  M.  D.  Second  edition, 
revised  and  improved.  In  one  large  volume,  oc- 
tavo, leather,  with  numerous  wood-cuts.  pp.  720. 
S3  50. 


CARSON  (JOSEPH),  M .  D., 

Professor  of  Materia  Medica  and  Pharmacy  in  the  University  of  Pennsylvania. 

SYNOPSIS  OF  THE  COURSE  OF  LECTURES  ON  MATERIA  MEDICA 

AND  PHARMACY,  delivered  in  the  University  of  Pennsylvania.    Second  and  revised  edi- 
tion.   In  one  very  neat  octavo  volume,  extra  c/oth,  of  208  pages.    $1  50. 


AND    SCIENTIFIC    PUBLICATIONS. 


CHURCHILL  (FLEETWOOD),  M.  D.,  M.  R.  I.  A. 
ON  THE  THEORY  AND  PRACTICE   OF  MIDWIFERY.     Edited,  with 

Notes  and  Additions,  by  D.  Francis  Condie,  M.  D.,  author  of  a  "Practical  Treatise  on  the 
Diseases  of  Children,"  &c.  With  139  illustrations.  In  one  very  handsome  octavo  volume, 
leather,    pp.510.     $3  00. 


To  bestow  praise  on  a  book  that  has  received  such 
marked  approbation  would  be  superfluous.  We  need 
only  say,  therefore,  that  if  the  first  edition  was 
thought  worthy  of  a  favorable  reception  by  the 
medical  public,  we  can  confidently  affirm  that  this 
will  be  found  much  more  so.  The  lecturer,  the 
practitioner,  and  the  student,  may  all  have  recourse 
to  its  pages,  and  derive  from  their  perusal  much  in- 
terest and  instruction  in  everything  relating  to  theo- 
retical and  practical  midwifery. — Dublin  Quarterly 
Journal  of  Medical  Science. 

A  work  of  very  great  merit,  and  such  as  we  can 
confidently  recommend  to  the  study  of  every  obste- 
tric practitioner. — London  Medical  Gazette. 

This  is  certainly  the  most  perfect  system  extant. 
It  is  the  best  adapted  for  the  purposes  of  a  text- 
book, and  that  which  he  whose  necessities  confine 
him  to  one  book,  should  select  in  preference  to  all 
others. — Southern  Medical  and  Surgical  Journal. 

The  most  popular  work  on  midwifery  ever  issued 
from  the  American  press. — Charleston  Med.  Journal. 

Were  we  reduced  to  the  necessity  of  having  but 
one  work  on  midwifery,  and  permitted  to  choose, 
we  would  unhesitatingly  take  Churchill. — Western 
Med.  and  Surg.  Journal. 

It  is  impossible  to  conceive  a  more  useful  and 
elegant  manual  than  Dr.  Churchill's  Practice  of 
Midwifery. — Provincial  Medical  Journal. 

Certainly,  in  our  opinion,  the  very  best  work  on 
the  subject  which  exists. — N.  Y.  Annalist. 


No  work  holds  a  higher  position,  or  is  more  de- 
serving of  being  placed  in  the  hands  of  th  tyro, 
the  advanced  student,  or  the  practitioner. — Medical 
Examiner. 

Previous  editions,  under  the  editorial  supervision 
of  Prof  R.  M.  Huston,  have  been  received  with 
marked  favor,  and  they  deserved  it;  but  this,  re- 
printed from  a  very  late  Dublin  edition,  can-fully 
revised  and  brought  up  by  the  author  to  the  present 
time,  does  present  an  unusually  accurate  and  able 
exposition  of  every  important  particular  embraced 
in  the  department  of  midwifery.  *  *  The  clearness, 
directness,  and  precision  of  its  teachings,  together 
with  the  great  amount  of  statistical  research  which 
its  text  exhibits,  have  served  to  place  it  already  in 
the  foremost  rank  of  works  in  i  his  department  at  re- 
medial science. — N.  O.  Med.  and  Surg.  Journal. 

In  our  opinion,  it  forms  one  of  the  best  if  not  the 
very  best  text-book  and  epitome  of  obstetric  science 
which  we  at  present  possess  in  the  English  lan- 
guage.— Monthly  Journal  of  Medical  Science. 

The  clearness  and  precision  of  style  in  which  it  is 
written,  and  the  great  amount  of  statistical  research 
which  it  contains,  have  served  to  place  it  in  the  first 
rank  of  works  in  this  departmentof  medical  science. 
—  N.  Y.  Journal  of  Medicine. 

Few  treatises  will  be  found  better  adapted  as  a 
text-book  for  the  student,  or  as  a  manual  for  the 
frequent  consultation  of  the  young  practitioner. — 
American  Medical  Journal. 


BY  the  same  author.     (J list  Issued.) 

ON  THE  DISEASES  OF  INFANTS   AND   CHILDREN.     Second  American 

Edition,  revised  and  enlarged  by  the  author.    Edited,  with  Notes,  by  W.  V.  Keating,  M.  D.    In 

one  large  and  handsome  volume,  extra  cloth,  of  over  700  pages.     $3  00,  or  in  leather,  $3  25. 

In  preparing  this  work  a  second  time  for  the  American  profession,  the  author  has  spared  no 
labor  in  giving  it  a  very  thorough  revision,  introducing  several  new  chapters,  and  rewriting  others, 
while  every  portion  of  the  volume  has  been  subjected  to  a  severe  scrutiny.  The  efforts  of  the 
American  editor  have  been  directed  to  supplying  such  information  relative  to  matters  peculiar 
to  this  country  as  might  have  escaped  the  attention  of  the  author,  and  the  whole  may,  there- 
fore, be  safely  pronounced  one  of  the  most  complete  works  on  the  subject  accessible  to  lire  Ame- 
rican Profession.  By  an  alteration  in  the  size  of  the  page,  these  very  extensive  additions  have 
been  accommodated  without  unduly  increasing  the  size  of  the  work. 

A  few  notices  of  the  former  edition  are  subjoined  : — 

We  regard  this  volume  as  possessing  more  claims  [  The  present  volume  will  sustain  the  reputation 
to  completeness  than  any  other  of  the  kind  with  I  acquired  by  the  author  from  his  previous  works. 
which  we  are  acquainted.  Most  cordially  and  ear-  J  The  reader  will  find  in  it  full  and  judicious  direc- 
nestly,  therefore,  do  we  commend  it  to  our  profession- :  tions  for  the  management  of  infants  at  birth,  and  a 
al  brethren,  and  we  feel  assured  that  the  stamp  of  '■  compendious,  but  clear  account  of  the  diseases  to 
their  approbation  will  indue  time  be  impressed  upon  j  which  children  are  liable,  and  the  most  successful 
it.  After  an  attentive  perusal  of  its  contents,  we  |  mode  of  treating  them.  We  must  not  close  this  no- 
hesitate  not  to  say,  that  it  is  one  of  the  most  com-  i  tice  without  calling  attention  to  the  author's  style, 
prehensive  ever  written  upon  the  diseases  of  chil-  I  which  is  perspicuous  and  polished  to  a  degree,  we 
dren,  and  that,  for  copiousness  of  reference,  extent  of  ;  regret  to  say,  not  generally  characteristic  of  medical 
research,  and  perspicuity  of  detail,  it  is  scarcely  to  ;  works.  We  recommend  the  work  of  Dr.  Churchill 
be  equalled,  and  not  to  be  excelled,  in  any  lan- 
guage.—  Dublin  Quarterly  Journal. 

After  this  meagre,  and  we  know,  very  imperfect 
notice  of  Dr.  Churchill's  work,  we  shall  conclude 
by  saying,  that  it  is  one  that  cannot  fail  from  its  co- 
piousness, extensive  research,  and  general  accuracy, 
to  exalt  still  higher  the  reputation  of  the  author  in 
this  country.  The  American  reader  will  be  particu- 
larly pleased  to  find  that  Dr.  Churchill  has  done  full 
justice  throughout  his  work  to  the  various  American 
authors  on  this  subject.  The  names  of  Dewees, 
Eberle,  Condie,  and  Stewart,  occur  on  nearly  every 
page,  and  these  authors  are  constantly  referred  to  by 
the  author  in  terms  of  the  highest  praise,  and  with 
the  most  liberal  courtesy. — The  Medical  Examiner. 


most  cordially,  both  to  students  and  practitioners. 
as  a  valuable  and  reliable  guide  in  the  treatment  of 
the  diseases  of  children. — Am.  Journ.  of  the  Mod. 
Sciences. 

AVe  know  of  no  work  on  this  department  of  Prac- 
tical Medicine  which  presents  so  candid  and  unpre- 
judiced a  statement  or  posting  up  of  our  actual 
knowledgeas  this. — N.  Y.  Journal  of  Medicine. 

Its  claims  to  merit  both  as  a  scientific  and  practi- 
cal work,  are  of  the  highest  order.  Whilst  we 
would  not  elevate  it  above  every  other  treatise  on 

the  same  subject,  we  certainly  believe  that  very  few 
are  equal  to  it,  and  none  superior. — Southern  Med. 
and  Surgical  Journal. 


BY   THE   SAME   AUTHOR. 

ESSAYS  ON  THE  PUERPERAL  FEVER,  AND  OTHER  DISEASES  PE- 
CULIAR TO  WOMEN.  Selected  from  the  writingsof  British  Authors  previous  to  the  close  of 
the  Eighteenth  Century.    In  one  neat  octavo  volume,  extra  cloth,  oi  about  450  pages.     $2  50. 


10 


BLANCHARD    &    LEA'S    MEDICAL 


CHURCHILL   (FLEETWOOD),    M.D.,  M.R.  I.A.,    «tc. 

ON  THE  DISEASES  OF  WOMEN;  including  those  of  Pregnancy  and  Child- 

bed.    A  iii-w  American  edition,  revised  by  the  Author.    With  Notes  and  Additions,  by  D  Fran- 

OM  Co  nii  IK.  M.  1>.,  author  ol  "A  Practical  Treatise  on  the  Diseases  of  Children."     With  nume- 

1)8  illustrations.    In  one  large  and  handsome  octavo  volume,  leather,  of  768  pages.    (Now  Ready, 

May.  IS  00. 

This  edition  of  Or.  Churchill's  very  popular  treatise  may  almost  be  termed  a  new  work,  so 
thoroughly  has  be  revised  it  in  every  portion.  It  will  be  found  greatly  enlarged,  and  thoroughly 
brought  up  to  the  most  recent  condition  of  the  subject,  while  the  very  handsome  series  of  illustra- 
tions introduced,  representing  such  pathological  conditions  as  can  be  accurately  portrayed,  present 
;i  novel  feature,  and  afford  valuable  assistance  to  the  young  practitioner.  Such  additions  as  ap- 
peared  ■  I.-  iral>le  lor  the  American  student  have  been  made  by  the  editor,  Dr.  Condie,  while  a 
narked  improvement  in  the  mechanical  execution  keeps  puce  with  the  advance  in  all  other  respects 
\N  |,  ch  i  lie  volume  lias  undergone,  while  the  price  has  been  kept  at  the  former  very  moderate  rate. 
.\  few  Helices  of  the  former  edition  are  subjoined  : — 

extent  that  Dr.  Churchill  does.  His,  indeed,  is  the 
only  thorough  treatise  we  know  of  on  the  sufiject  ; 
and  it  may  he  commended  to  practitioners  and  stu- 
dents as  a  masterpiece  in  its  particular  department. 
The  former  editions  of  this  Work  have  been  com- 
mended strongly  in  this  journal,  and  they  have  won 
heir  v'mv  to  an  extended,  and  a  well-deserved  popu- 
larity. This  fifth  edition,  hefore  us.  is  well  calcu- 
lated to  maintain  Dr.  Churchill's  high  reputation. 
It  was  revised  and  enlarged  by  the  author,  for  his 
American  publishers,  and  it  seems  to  us  that  there  is 
scarcely  any  species  of  desirable  information  on  its 
subjects  that  may  not  be  found  in  this  work. — The 
Western  Journal  of  Medicine  and  Surgery. 


It  comprises,  unquestionably,  <  ne  of  the  most  ex- 
acl  and  comprehensive  expositions  of  the  present 
state  of  medical  knowledge  in  respect  to  the  diseases 
of  women  that  has  yet  I  een  published. — Am.Journ. 
M  I .  Sciences,  July,  1857. 

We  bail  with  much  pleasure  the  volume  before 
us,  thoroughly  revised,  corrected,  and  brought  up 
to  the  latest  date,  by  Dr.  Churchill  himself,  and 
rendered  still  more  valuable  by  notes,  from  the  ex- 
perienced and  aide  pen  of  Dr.  D.  F.  Condie,  of  Phil- 
ad<  Iphia.—  Southern  Mid.  and  Surg.  Journal,  Oct. 
1&57. 

This  work  is  the  most  reliable  which  we  possess 
on  tti is  subject;  and  is  deservedly  popular  with  the 
profetsion. — Charleston  Med.  Journal,  July,  1857. 

Dr.  Churchill's  treatise  on  the  Diseases  of  Women 
is,  perhaps,  i  he  most  popular  of  his  works  with  the 
profession  m  this  country.  It  has  been  very  gene- 
rally received  both  as  a  text-book  and  manual  of 
practice.  Tin'  present  edition  has  undergone  the 
most  elaborate  revision,  and  additions  of  an  import- 
ant character  have  been  made,  to  render  it  a  com- 
plete exponent  of  the  present  state  of  our  knowledge 
of  these  diseases. — N,  Y.  Journ.  of  Med.,  i^ept.  Is.37. 

We  now  regretfully  take  leave  of  Dr.  Churchill's 
book.  Had  our  typographical  limits  permitted,  we 
should  gladly  have  borrowed  more  from  its  richly 
stored  pages.  In  conclusion,  we  heartily  recom- 
mend it  to  the  profession,  and  would  at  the  same 
time  express  our  firm  conviction  that  it  will  not  only 
add  to  the  reputation  of  its  author,  but  will  prove  a 
work  of  great  and  extensive  utility  to  obstetric 
practitioners. — Dublin  Mediral  Press. 

We  know  of  no  author  who  deserves  that  appro- 
bation, on  "  the  diseases  of  females,"  to  the  same 


We  are  gratified  to  announce  a  new  and  revised 
edition  of  Dr.  Churchill's  valuable  work  on"  the  dis- 
eases of  females  We  have  ever  regarded  it  as  one 
of  the  very  best  works  on  the  subjects  embraced 
within  its  scope,  in  the  English  language;  and  the 
present  edition,  enlarged  and  revised  by  the  author, 
renders  it  still  more  entitled  to  the  confidence  of  the 
profession.  The  valuable  notes  of  Prof.  Huston 
have  been  retained,  and  contribute,  in  no  small  de- 
gree, to  enhance  the  value  of  the  work.  It  is  a 
source  of  congratulation  that  the  publishers  have 
permitted  the  author  to  be,  in  this  instance,  his 
own  editor,  thus  securing  all  the  revision  which 
an  author  alone  is  capable  of  making. — The  Western 
Lanret. 

Asa  comprehensive  manual  for  students,  or  a 
work  of  reference  for  practitioners,  we  only  speak 
with  common  justice  when  we  say  that  it  surpasses 
any  other  that  has  ever  issued  on  the  same  sub- 
ject from  the  British  press. —  The  Dublin  Quarterly 
Journal. 


DICKSON   (S.    H.),    M.  D., 

Professor  of  Institutes  and  Practice  of  Medicine  in  the  Medical  College  of  South  Carolina. 

ELEMENTS  OP  MEDICINE;    a  Compendious  View  of  Pathology  and  Thera- 

peutics,  or  the  History  and  Treatment  of  Diseases.     In  one  large  and  handsome  octavo  volume, 
of  7")0  pages,  leather      (Lately  Issued.)     $3  75. 

As  an  American  text-book  on  the  Practice  of  Medicine  for  the  student,  and  as  a  condensed  work 
of  reference  for  the  practitioner,  this  volume  will  have  strong  claims  on  the  attention  of  the  profession. 
Few  physicians  have  had  wider  opportunities  than  the  author  for  observation  and  experience,  and 
few  perhaps  have  used  them  better.  As  the  result  of  a  life  of  study  and  practice,  therefore,  the 
present  volume  will  doubtless  be  received  with  the  welcome  it  deserves. 

This  book  is  eminently  what  it  professes  to  be ;  a  I  merits,  and  we  have  no  hesitation  in  predicting  for 


distinguished  merit  in  these  days.  Designed  for 
"  Teachers  and  students  of  Medicine,"  and  admira- 
bly suited  to  their  wants,  we  think  it  will  he  received, 
on  its  own  merits,  with  a  hearty  welcome. — Boston 
Med.  and  Surg.  Journal. 

Indited  by  one  of  the  most  accomplished  writers 
of  our  country,  as  well  as  by  one  who  has  long  held 
a  high  position  among  teachers  and  practitioners  of 
medicine,  tins  work  is  entitled  to  patronage  and 
caret. il  study.  The  learned  author  has  endeavored 
to  condense  in  this  volume  most  of  the  practical 
matter  contained  in  Ins  former  productions,  so  as  to 
adapt  it  to  the  use  of  those  who  have  not  time  to 
devote  to  more  extensive  works. — Southern  Med.  and 
Surg.  Journal. 

Prof.  Dickson's  work  supplies,  to  a  great  extent, 
a  desideratum  long  felt  in  American  medicine. — N. 
O.  Med.  and  Surg.  Journal. 

Estimating  this  work  according  to  the  purpose  for 
which  it  is  designed,  we  must  think  highly  of  its 


it  a  favorable  reception  by  both  students  and  teachers. 

Not  professing  to  be  a  complete  and  comprehensive 
treatise,  it  will  not  be  found  full  in  detail,  nor  filled 
with  discussions  of  theories  and  opinions,  but  em- 
bracing all  that  is  essential  in  theory  and  practice, 
it  is  admirably  adapted  to  the  wants  of  the  American 
student.  Avoiding  all  that  is  uncertain,  it  presents 
more  clearly  to  the  mind  of  the  reader  that  which  is 
established  and  verified  by  experience.  The  varied 
and  extensive  reading  of  the  author  is  conspicuously 
apparent,  and  all  the  recent  improvements  anil  dis- 
coveries in  therapeutics  and  pathology  are  chroni- 
cled in  its  pages. —  Charleston  Med   Journal. 

In  the  first  part  of  the  work  the  subject  of  gene- 
ral pathology  is  presented  in  outline,  giving  a  beau- 
tiful picture  of  its  distinguishing  features,  and 
throughout  the  succeeding  chapters  we  find  that  he 
has  kept  scrupulously  within  the  bounds  of  sound 
reasoning  and  legitimate  deduction.  .Upon  the 
whole,  we  do  not  hesitate  to  pronounce  it  a  superior 
work  in  its  class,  and  that  Dr.  Dickson  merits  a 
place  in  the  first  rank  of  American  writers.—  Western 
Lancet. 


AND    SCIENTIFIC    PUBLICATIONS 


II 


DRUITT   (ROBERT),   M.R.C.S.,   &.c. 
THE  PRINCIPLES  AND  PRACTICE   OF  MODERN  SURGERY.     Edited 

by  F.  \V.  Sargent,  M.  D.,  author  of  «  Minor  Surgerv,"  &c.  Illustrated  with  one  hundred  and 
ninety-three  wood-engravings.  In  one  very  handsomely  printed  octavo  volume,  leather,  of  576 
large  pages.     $3  00. 


Dr.  Druitt's  researches  into  the  literature  of  his 
subject  have  been  not  only  extensive,  but  well  di- 
rected;  the  most  discordant  authors  are  fairly  and 
impartially  quoted,  and,  while  due  credit  is  given 
to  each,  their  respective  merits  are  weighed  with 
an  unprejudiced  hand.  The  grain  of  wheat  is  pre- 
served, and  the  chaff  is  unmercifully  stripped  off. 
The  arrangement  is  simple  and  philosophical,  and 
the  style,  though  clear  and  interesting,  is  80  precise, 
that  the  book  contains  more  information  condensed 
into  a  few  words  than  any  other  surgical  work  with 
which  we  are  acquainted.— London  Medical  Times 
and  Gazette. 

No  work,  in  our  opinion,  equals  it  in  presenting 
so  much  valuable  surgical  matter  in  so  small  a 
compass.— St.  Louis  Med.  and  Surgical  Journal. 

Druitt's  Surgery  is  too  well  known  to  the  Ameri- 
can medical  profession  to  require  its  announcement 
anywhere.  Probably  no  work  of  the  kind  has  ever 
been  more  cordially  received  and  extensively  circu- 
lated than  this.  The  fact  that  it  comprehends  in  a 
comparatively  small  compass,  all  the  essential  ele- 
ments of  theoretical  and  practical  Surgery — tiiat  it 
is  found  to  contain  reliable  and  authentic  informa- 
tion on  the  nature  and  treatment  of  nearly  all  surgi- 
cal affections — is  a  sufficient  reason  for  the  liberal 
patronage  it  has  obtained.  The  editor,  Dr.  F.  W. 
Sargent,  has  contributed  much  to  enhance  the  value 
of  the  work,  by  such  American  improvements  as  are 
calculated  more  perfectly  to  adapt  it  to  our  own 
views  and  practice  in  this  country.  It  abounds 
everywhere  with  spirited  and  life-like  illustrations, 
which  to  the  young  surgeon,  especially,  are  of  no 
minor  consideration.  Every  medical  man  frequently 
nt/eds  just  such  a  work  as  this,  for  immediate  refer- 
ence in  moments  of  sudden  emergency,  when  he  has 
not  time  to  consult  more  elaborate  treatises. — The 
Ohio  Medical  and  Surgical  Journal. 

The  author  has  evidently  ransacked  every  stand- 
ard treatise  of  ancient  and  modern  times,  and  all  that 


is  really  practically  useful  at  the  bedside  will  be 
found  in  a  form  at  once  clear,  distinct,  and  interest- 
ing.— Edinburgh  Monthly  Medical  Journal. 

Druitt's  work,  condensed,  systematic,  lucid,  and 
practical  as  it  is,  beyond  most  works  on  Surgery 
accessible  to  the  American  student,  has  had  much 
currency  in  this  country,  and  under  its  present  au- 
spices promises  to  rise  to  yet  higher  ta.voi.-Tkt 
Western  Journal  of  Medicine  and  Surgery. 

The  most  accurate  and  ample  resume  of  the  pre- 
sent state  of  Surgery  that  we  areacquainted  with.— 
Dublin  Medical  Journal. 

A  better  book  on  the  principles  and  practice  of 
Surgery  as  now  understood  in  England  and  America, 
has  not.  been  given  to  the  profession.— Boston  Medi- 
cal and  Surgical  Journal. 

An  unsurpassable  compendium,  not  only  of  Sur- 
gical, but  of  Medical  Practice.— London  Medical 
Gazette. 

This  work  merits  our  warmest  commendations, 
and  we  strongly  recommend  it  to  young  surgeons  as 
an  admirable  digest  of  the  principles  and  practice  of 
modern  Surgery. — Medical  Gazette. 

It  may  be  said  with  truth  that  the  work  of  Mr. 
Druitt  affords  a  complete,  though  brief  and  con- 
densed view,  of  the  entire  field  of  modern  surgery. 
We  know  of  no  work  on  the  same  subject  having  the 
appearance  of  a  manual,  which  includes  so  many 
topics  of  interest  to  the  surgeon  ;  and  the  terse  man- 
ner in  which  each  has  been  treated  evinces  a  most 
enviable  quality  of  ijiind  on  the  part  of  the  author, 
who  seems  to  have  an  innate  power  of  searching 
out  and  grasping  the  leading  facts  and  features  of 
the  most  elaborate  productions  of  the  pen.  It  is  a 
useful  handbook  for  the  practitioner,  and  we  should 
deem  a  teacher  of  surgery  unpardonable  who  did  not 
recommend  it  to  his  pupils.     In  our  own  opinion,  it 

is  admirably  adapted  to  the  wants  of  the  student. 

Provincial  Medical  and  Surgical  Journal. 


DUNGLISON,    FORBES,   TWEEDIE,    AND   CONOLLY. 
THE  CYCLOPAEDIA  OP  PRACTICAL  MEDICINE:  comprisin«z Treatises  on 

the  Nature  and  Treatment  of  Diseases,  Materia  Medica,  and  Therapeutics,  Diseases  of  Women 
and  Children,  Medical  Jurisprudence,  &c.  &c.      in  four  large  super-royal  octavo  volumes,  of 
3254  double-columned  pages,  strongly  and  handsomely  bound,  with  raised  bands.     $12  00. 
*#*  This  work  contains  no  less  than  four  hundred  and  eighteen  distinct  treatises,  contributed  by 

sixty-eight  distinguished  physicians,  rendering  it  a  complete  library  of  reference  for  the  country 

practitioner. 


The  most  complete  work  on  Practical  Medicine 
extant;  or,  at  least,  in  our  language.—  Buffalo 
Medical  and  Surgical  Journal. 

For  reference,  it  is  above  all  price  to  every  prac- 
titioner.—  Western  Lancet. 

One  of  the  most  valuable  medical  publications  of 
the  day — as  a  work  of  reference  it  is  invaluable. — 
Western  Journal  of  Medicine  and  Surgery. 

It  has  been  to  us,  both  as  learner  and  teacher,  a 
work  for  ready  and  frequent  reference,  one  in  which 
modern  English  medicine  is  exhibited  in  the  most 
advantageous  light. — Medical  Examiner. 

We  rejoice  that  this  work  is  to  be  placed  within 
the  reach  of  the  profession  in  this  country,  it  being  { 
unquestionably  one  of  very  great  value  to  the  prae-  I 


titioner.  This  estimate  of  it  has  not  been  formed 
from  a  hasty  examination,  but  after  an  intimate  ac- 
quaintance derived  from  frequent  consultation  of  it 
during  the  past  nine  or  ten  years.  The  editors  are 
practitioners  of  established  reputation,  ami  the  list 
of  contributors  embraces  many  of  the  most  eminent 
professors  and  teachers  of  London,  Edinburgh,  Dub- 
lin, and  Glasgow.  It  is,  indeed,  thegreat  merit  of 
this  work  that  the  principal  articles  have  been  fur- 
nished by  practitioners  who  have  not  only  devoted 
especial  attention  to  the  diseases  about  which  they 
have  written,  but  have  also  enjoyed  opportunities 
for  an  extensive  practical  acquaintance  with  them, 
and  whose  reputation  carries  the  assurance  of  their 
competency  justly  to  appreciate  the  opinions  of 
others,  while  it  stamps  their  own  doctrines  with 
high  and  just  authority. — American  Medical  Journ. 


DEWEES'S  COMPREHENSIVE    SYSTEM   OF  l 
MIDWIFERY.     Illustrated  by  occasional  cases 
and  many  engravings.     Twelfth  edition,  with  the 
author's  last  improvements  and   corrections      In 
one  octavo  volume,  extra  cloth,  of  GOO  pages.  $3  20. 

DEWEES'S  TREATISE  ON  THE  PHYSICAL 
AND  MEDICAL  TREATMENT  OF  CHILD- 
REN. Tenth  edition.  In  one  volume,  octavo, 
extra  cloth,  54S  pages.     $2  80. 

DEWEES'S  TREATISE  ON  THE  DISEASES 
OF  FEMALES.  Tenth  edition.  In  one  volume, 
octavo,  extra  efoth,  532  pages,  with  plates.  $3  00. 


DANA  ON  ZOOPHYTES  AND  CORALS.  In  one 

volume,  imperial   quarto,  extra  cloth,  with  \\  . 
cuts.    $15  00.     Also,  AN  ATLAS,  in  one  volume. 
imperial  folio,  with  sixty-one  magnificent  colored 
plates.     Bound  in  half  morocco.     $30  HO. 

DE  LA  BECHE'S  GEOLOGICAL   OBSERVER. 

In  one  very  large  and  handsome  octavo  volume,  ex- 
tra cloth,  of  700  pages,  with  300  wood-cats.  S4  00. 
FRICK  ON  RENAL  AFFECTIONS;  theirDiag- 
nosis  and  Pathology.  'With  illustrations.  One 
volume,  royal  12mo.,  extra  cloth.     75  cents. 


12 


BLANCHARU   «te    LEA'S    MEDICAL 


DUNGLISON    (ROBLEY),    M.D., 
Professor  of  Institute!  of  Medicine  in  the  Jefferson  Medical  College,  Philadelphia. 

NEW  AND  ENLARGED  EDITION,  Now  Ready. 

MEPTCAL  LEXICON;   a  Dictionary  of  Medical  Science,  containing  a  concise 

Uion  of  the  various  SubjectB  and  Terms  of  Anatomy,  Physiology,  Pathology,  Ilvgiene, 

(utics   Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medical  jurisprudence,  1  tehtistry, 

lot  ices  of  Climate  mid  of  .Mineral  Waters;  Formula1  for  Officinal,  Empirical,  and  Dietetic 

Preparations,  &c.    With  French  and  other  Synonymes.    Fifteenth  edition,  revised  and  very 

,_.,,.  rged.     In  one  very  large  and  handsome  octavovolume;  of  992  double-columned  pages, 

m  small  :\  pe ;  strongly  bound  in  leather,  with  raised  bands.     Price  $4  00. 

No  care,  labor,  "r  expense  has  been  spared  in  the  preparation  of  this  edition  to  render  it  in  every 
r»t  worthy  a  continuance  of  the  very  remarkable  favor  which  u  has  hitherto  enjoyed.    The 
ale  of  I'll' 1 1  en  large  editions,  and  the  constantly  increasing  demand,  show  thai  it  t~  regarded 
by  tli('  profession  as  the  standard  authority.     Stimulated  by  this  lacf,  the  author  has  endeavored  in 
presenl  revision  to  introduce  whatever  might  be  necessary  to  make  it  a  satisfactory  and  desira- 
I,],  —  ifrol  indispensabb — lexicon,  in  which  the  student   may  search  without  disappointment  for 
every  term  thai  has  been   legitimated  in  the  nomenclature  of  the  science".     To  accomplish  this, 
e  additions  have  been  found  requisite,  and  the  extent  of  the  author's  labors  may  be  estimated 
from  the  fact  thai  aboul  Six  Thousand  subjects  and  terms  have  been  introduced  throughout,  ren- 
dering  the  whole  number  of  definitions  about  Sixty  Thousand,  to  accommodate  which,  the  num- 
ber ol  pages  has  been  increased  by  nearly  a  hundred,  notwithstanding  an  enlargement  in  the  size 
of  the  page.     The  medical  press,  both  in  this  country  and  in  England,  has  pronounced  the  work  in- 
dispensable to  all  medical  students  and  practitioners,  and  the  piesent  improved  edition  will  not  lose 
that  enviable  reputation. 

The  publishers  have  endeavored  to  render  the  mechanical  execution  worthy  of  a  volume  of  such 
universal  use  in  daily  reference.  The  greatest  care  has  been  exercised  to  obtain  the  typographical 
uracy  so  necessary  in  a  work  of  the  kind.  By  the  small  but  exceedingly  clear  type  employed, 
an  immeuse  amount  ol  matter  is  condensed  in  its  thousand  ample  pages,  while  the  binding  will  be 
found  strong  and  durable.  With  all  these  improvements  and  enlargements,  the  price  has  been  kept 
at  the  former  very  moderate  rate,  placing  it  within  the  reach  of  all. 

tells  as  ill  his  preface  that-  he  has  added  about  six 
thousand  terms  and  subjects  to  this  edition,  which, 
before,  was  considered  universally  as  the  best  work 
of  the  kind  in  any  language. — Silliman's  Journal, 
March,  1&5S. 

He  has  razed  his  gigantic  structure  to  the  founda- 
tions, and  remodelled  and  reconstructed  the  entire 
pile.  No  less  than  six  thousand  additional  subjects 
ami  terms  are  illustrated  and  analyzed  in  this  new 
edition,  swelling  the  grand  aggregate  to  heyond 
sixty  thousand  .'  Thus  is  placed  before  the  profes- 
sion a  complete  and  thorough  exponent  el"  medical 
terminology,  without  rival  01  possibility  of  rivalry. 
— Nashville  Journ.  of  Med.  and  Surg..  Jan.  1858. 

It  is  universally  acknowledged,  we  belb  ve,  that 
this  work  is  incomparably  the  best  and  most  com- 
plete Medical  Lexicon  in  the  English  language. 
The  amount  of  labor  which  the  distinguished  author 
has  bestowed  upon  it  is  truly  wonderful,  and  the 
learning  and  research  displayed  in  its  preparation 
are  equally  remarkable.  Comment  and  commenda- 
tion are  unnecessary,  as  no  one  at  the  present  day 
thinks  of  purchasing  any  other  Medical  Dictionary 
than  this. —  St.  Louis  Med.  and  Surg.  Journ.,  Jan. 
1858. 

It  is  the  foundation  stone  of  a  good  medical  libra- 
ry, and  should  always  he  included  in  the  first  list  of 
books  purchased  by  the  medical  student. — Am.  Med. 
Month/!/,  Jan,  lfs.56. 

A  very  perfect  work  of  the  kind,  undoubtedly  the 
most  perfect  in  the  English  language. — Med.  and 
Surg.  Reporter,  Jan.  J858. 

It  is  now  emphatically  the  Medical  Dictionary  of 
the  English  language,  and  for  it  there  is  no  substi- 
tute.—A'.  H.  Med.  Journ.,  Jan.  1858. 

It  is  scarcely  necessary  to  remark  that  any  medi- 
cal library  wanting  a  copy  of  Dunglison's  Lexicon 
must  be  imperfect. — Cin.  Lancet.  Jan.  I 

We  have  ever  considered  it  the  lies'  authority  pub- 
lished, and  the  present  edition  we  may  safely  say  has 
no  equal  in  the  world — Peninsular  Med.  Journal, 
Jan.  1858. 

The  most  complete  authority  on  the  subject  to  he 
found  in  any  language. —  Va.  Med.  Journal ,  Feb.  '5t>. 


This  work,  the  appearance  of  the  fifteenth  edition 

i  f  which,  it  has  In e  ear  duty  and  pleasure  to 

ami' ia nee.  is  perhaps  the  most  stupendous  monument 
of  labor  and  erudition  in  medical  literature.  One 
would  hardly  suppose  after  constant  use  of  the  pre- 
ceding editions,  where  we  have  never  failed  to  find 
a  sufficiently  full  explanation  of  even  medical  term, 
that  in  this  edition  "  about  six  thousand  subjects 
and  ti  rms  have  been  added,"  with  a  careful  revision 
and  corn  ction  of  the  entire  work.  It  is  only  neces- 
sary to  announce  the  advent  of  this  edition  to  make 
it  occupy  the  place  of  the  preceding  one  on  the  table 
of  every  medical  man.  as  it  is  without  doubt  the  best 
and  most  comprehensive  work  of  the  kind  which  has 
ever  appeared. —  Bvjt'alo  Med.  Journ.,  Jan.  1S5S. 

The  work  is  a  monument  of  patient  research, 
skilful  judgment,  and  vast,  physical  labor,  that  will 
perpetuate  the  name  of  the  author  more  effectually 
than  any  possible  device  of  stone  or  metal.  Dr. 
Dunglison  deserves  the  thanks  not  only  of  the  Ame- 
rican profession,  but.  of  the  whole  medical  world. — 
North  Am.  Medico- Chir.  Review,  Jan.  lbSS. 

A  Medical  Dictionary  better  adapted  for  the  wants 
of  the  profession  than  tiny  other  with  which  we  are 
acquainted,  and  of  a  character  which  places  it  far 
above  comparison  and  competition. — Am.  Journ. 
Mnl.  Sri' nets,  Jan.  J858. 

We  need  only  say,  that  the  addition  of  6,000  new 
terms,  with  their  accompanying  definitions.  ma)  be 
said  to  constitute  a  new  work,  by  itself.  We  have 
examined  the  Dictionary  attentively,  and  are  most 
py  to  pronounce  it  unrivalled  of  its  kind.  The 
erudition  displayed,  and  the  extraordinary  industry 
which  must  have  been  demanded,  in  its  preparation 
and  perfection,  redound  to  the  lasting  credit  of  its 
author,  and  have  furnished  us  with  a  volume  indis- 
,  nsable  at  the  present  day.  to  all  who  would  find 
themselves  aw  niveau  with  the  Inulies t  standards  of 
medical  in  format]  in. — Boston  Medical  and  Surgical 

Journal.  Dec.  31,  1857. 

Good  lea  ind  encyclopedic  works  generally, 

are  the  most  labor-saving  contrivances  which  lite- 
rary men  enjoy;  and  the  labor  which  is  required  to 
produce  them  in  the  perfect,  manner  of  this  example 
is  something  appalling  to  contemplate.    The  author  ; 


BY   THE   SAME   AUTHOR. 

THE  PRACTICE  OF  MEDICINE.     A  Treatise  on  Special  Pathology  and  The- 
rapeutics.   Third  Edition.    In  two  large  octavo  volumes,  leather,  of  1,500  pages.    $6  25. 


AND    SCIENTIFIC    PUBLICATIONS.  13 


DUNGLISON    (ROBLEY),    M.D., 
Professor  of  Institutes  of  Medicine  in  the  Jefferson  Medical  College,  Philadelphia. 

HUMAN    PHYSIOLOGY.      Eighth   edition.      Thoroughly  revised   and  exten- 
sively modified  and  enlarged,  with  five  hundred  and  thirty-two  illustrations.     In  two  Iar"-e  and 
handsomely  primed  octavo  volumes,  leather,  of  about  1600  pages.     {Just  Issued,  1856.)      -  7  00. 
In  revising  this  work  lor  its  eighth  appearance,  the  author  has  spared  no  labor  to  render  it  worthy 
a  continuance  of  the  very  preat  favor  which  has  been  extended  to  it  by  the  profession.     The  whole 
contents  have  been  rearranged,  and  to  a  great  extent  remodelled  ;  the"  investigations  which  of  late 
years  have  been  so  numerous  and  so  important,  have  been  carefully  examined  and  incorporated 
and  the  work  in  every  respect  has  teen  brought  up  to  a  level  with  the  present  state  of  the  subject 
The  object  of  the  author  has  been  to  render  it  a  concise  but  comprehensive  treatise,  containing  the 
whole  body  of  physiological  science,  to  which  the  student  and  man  of  science  can  at  all  times  refer 
with  the  certainty  of"  finding  whatever  they  are  in  search  of,  fully  presented  in  all  its  aspects  ;  and 
on  no  former  edition  has  the  author  bestowed  more  labor  to  seciire  this  result. 

We  believe  that  it  can  truly  be  said.no  more  com-  The  best   work  of  the  kind    in  the  English  lan- 

plete  repertory  of  facls  upon   the   subject  treated,  guage  —  Siltimnn's  Jnvrnal. 

can  anvwhere  befound.     The  author  has.  moreover,  TU  „,„„  „,      ....       .,           ..       . 

that  enviable  tact  at  description   and  that  facility  ?  fr P* X  ,ci  Z        i?       ?,?  ""'     ''  P7feCt 

and  ease  of  expression  wliich  render  him  peculiarly  T"'l  U   «„?£  I     •  "1                   the  present  hour 

acceptable  to 'the  casual,  or  the   studious   reader.  $*?,  *,.  ^"n^\ u '"?,"  W'i         •'T'"1'6  'if 

This   faculty,   so  requisite   in   setting  forth    many  filj1  i?   ' HI?*1  Z  J,  7     V     ' <      n '>'*    '"'  'tadentwill 

eraver  and  less  attractive  subjects,  lends  additional  s^nt  1856              tBtiw—Nashville   Journ.   of  VLtd. 

'•harms  to  one   always   fascinating. — Boston    Med.  '         '      °  ' 

and  Surg.  Journal,  Sept.  1856.  That  he  has  succeeded,  most  admirably  succeeded 

in  his  purpose,  is  apparent  from  the  appearai 

lne  most  complete  and  satisfactory  system   of  an  eighth  edition.     It  is  now  the  irreat encyclopedia 

Physiology  in  the  English  language.— Amer.  Med.  on  the  subject,  and  worthy  of  a  place  in  every  phy- 

Joumal.  sician's  library. — Western  Lancet,  Sept.  1S.3U. 

EY  the  same  author.     (Now  Ready.) 

GENERAL    THERAPEUTICS    AND    MATERIA  MEDIC  A;   adapted  for  a 

Medical  Text-book.  With  Indexes  of  Remedies  and  of  Diseases  and  their  Remedies.  Sixth 
Edition-,  revised  and  improved.  With  one  hundred  and  ninety-three  illustrations.  In  two  lar°-e 
and  handsomely  printed  octavo  vols.,  leather,  of  about  1100  pages.    $6  00. 

From  the  Author's  Preface. 

"  Another  edition  of  this  work  being  called  for,  the  author  has  subjected  it  to  a  thorough  and  careful 
revision.    It  ha-;  been  gratifying  to  him  that  it  has  been  found  so  extensively  useful  by  thi  bom 

il  was  e-pecially  intended,  as  to  require  that  a  sixth  edition  should  be  issued  in  so  sh  irt  1  time  afier 
the  publication  of  a  filth.  Grateful  for  the  favorable  reception  of  the  work  by  the  profession,  he  has 
bestowed  on  the  preparation  of  the  present  edition  all  those  cares  which  were  demanded  by  the 
former  editions,  and  has  spared  no  pains  to  render  it  a  faithful  epitome  of  General  Therapeutics 
and  Materia  Medica.  The  copious  Indexes  of  Remedies  and  of  Diseases  and  their  Remedies  can- 
not fail,  the  author  conceives,  to  add  materially  to  the  value  of  the  work." 

This  work  is  too  widely  and  too  favorably  known  to  require  more  than  the  assurance  that  the 
author  has  revised  it  with  his  customary  industry,  introducing  whatever  has  been  found  necessary 
to  bring  it  on  a  level  with  the  most  advanced  condition  of  the  subject.  The  number  of  illustrations 
has  been  somewhat  enlarged,  and  the  mechanical  execution  of  the  volumes  will  be  found  to  have 
undergone  a  decided  improvement. 

by  the  same  author.     (A  new  Edition.) 

NEW  REMEDIES,  WITH  FORMULA  FOR  THEIR  PREPARATION  AND 

ADMINISTRATION.  Seventh  edition,  with  extensive  Additions.  In  one  very  large  octavo 
volume,  leather,  of  770  pages.     (Just  Issued.)     $3  75. 

Another  edition  of  the  "  New  Remedies"  having  been  called  for,  the  author  has  endeavored  to 
add  everything  of  moment  ihat  has  appeared  since  the  publication  of  the  last  edition. 

The  chief  remedial  means  which  have  obtained  a  place,  for  the  first  time,  in  this  volume,  either 
owing  to  their  having  been  recently  introduced  into  pharmacology,  or  to  their  having  received  novel 
applications — and  which,  consequently,  belong  to  the  category  of  "  New  Remedies" — are  the  fol- 
lowing : — 

Apiol,Caffein,  Carbazotic  acid,  Cauterization  and  catheterism  of  the  larynx  and  trachea.  Cedron, 
Cerium.  Chloride  of  bromine,  Chloride  of  iron,  Chloride  of  sodium.  Cinchonicine,  Cod-liver  olein, 
Congelation,  Eau  de  Pagliari,  Galvanic  cautery,  Hydriodic  ether,  Hyposulphite  of  soda  and  silver, 
Inunction,  Iodide  of  sodium,  Nickel,  Permanganate  of  potassa,  Phosphate  of  lime.  Pumpkin.  Quinidia, 
Rennet,  Saccharine  carbonate  of  iron  and  manganese.  Santonin,  Tellurium,  and  Traumaticine. 

The  articles  treated  of  in  the  former  editions  will  befound  to  have  undergone  considerable  ex- 
pansion in  this,  in  order  that  the  author  might  be  enabled  to  introduce,  as  far  as  practicable,  the 
results  of  the  subsequent  experience  of  others,  as  well  as  of  his  own  observation  and  reflection; 
and  to  make  the  work  still  more  deserving  of  the  extended  circulation  with  which  the  preceding 
editions  have  been  favored  by  the  profession.  By  an  enlargement  of  the  page,  the  numerous  addi- 
tions have  been  incorporated  without  greatly  increasing  the  bulk  of  the  volume. — Pre/ 

One  of  the  most  useful  of  the  author's  works. —  I  The  great  learning  ol  the  author,  and  his  remark- 
Sovtkurn  Medical  and  Surgical  Journal,  able  industry  in   pushing  his   researches  into  every 

This  elaborate  and  useful  volume  should  be  source  whence  information  is  derivable,have  enabled 
found  in  every  medical  library,  for  as  a  book  of  re-  '"">  to  throw  together  an  extensive  mass  of  tacts 
ference,  for  physicians,  it  is  unsurpassed  by  any  Bnd,  statements,  accompanied  by  lull  reference  to 
other  Work  in  existence,  and  the  double  index  for  authorities;  which  last  feature  renders  the  work 
diseases  and  for  remedies,  will  be  found  greatly  to  practically  valuable  to  investigators  who  desire  to 
enhance  its  value— Mu>  York  Med.  Gazette.  examine  the  original  papers— The  Am,  r, can  Journal 

of  Pharmacy. 


M 


BLANCHARD  &  LEA'S  MEDICAL 


ERICHSEN    (JOHN), 
Professor  of  Surgery  in  University  College,  London,  &.C. 

THE  SCIENCE  AND  ART  OF  SURGERY;  being  a  Treattse  on  Suraical 

Inukiks,  DlSBASKB,  and  Operations.  Edited  by  John  H.  BBITfTON,  M.  D.  Illustrated  with 
three  hundred  and  eleven  engravings  on  wood.  In  one  large  and  handsome  octavo  volume,  of 
over  Dine  hundred  closely  printed  pages,  leather,  raised  hands.     $4  25. 

li  is.  in  oar  h u  111 1 > I •*  judgment,  decidedly  the  best 
book  of  the  kind  in  ihe  Rnglish  language.    Strange 


that  jnai  such  books  arc  notoflener  produced  by  puii 
lie  tender-  of  surgery  in  this  country  and  Great 
Britain  indeed,  it  i-  a  matlerof great  astonishment, 
hot  no  less  true  than  astonishing,  that  of  the  many 
work- on  surgery  republished  in  this  country  within 
the  la-i  fifteen  or  twenty    years  n*  text- booh; s  for 

mediriil  students,  Ihis  i-  the  01  ly  one  that  even  ap- 
prnzimate8  10  the  fulfilment  of  the  peculiar  want?  of 
young  men  just  entering  upon  the  study  of  thi«  branch 

of  i  he  pn  d'es- ion. —  Western  Jour. of  Med.  anl  Surgery. 

It*  value  is  greatly  enhanced  by  a  very  copious 
well- arranged  index.  We  regard  this  as  one  of  the 
most  valuable  contributions  to  modem  surgery.  To 
one  entering  his  novitiate  of  practice,  we  regard  it 
ih'-  mo*'  serviceable  guide  which  he  can  consult.  He 
will  find  a  fulness  of  detail  leading  him  th  rough  every 
step  of  the  operation,  and  not  deserting  him  until  the 
final  issue  of  the  ea-e  is  decided  For  the  same  rea- 
son we  recommend  it  to  those  whose  routine  of  prac- 
tice lies  in  such  parts  of  the  country  that  they  must 


rarely  encounter  cases  requiring  surgical  manage- 
in  e  n  t . — Stethoscope. 

Embracing,  as  will  he  perceived,  the  whole  surgi- 
cal domain,  and  each  division  of  itself  almost  com- 
plete and  perfect,  each  chapter  full  and  explicit,  each 
subject  faithfully  exhibited,  we  can  only  express  our 
estimate  of  it  in  the  aggregate.  We  consider  it  an 
excellent  contribution  to  surgery,  as  probably  the 
lie-'  sintrle  volume  now  extant  on  the  subject,  and 
with  great  pleasure  we  add  it  to  our  text-hooks  — 
Nashville  Journal  of  Medicine  and  Surgery. 

Prof.  Enchsen's  work,  for  its  size,  has  not  been 
surpassed;  his  nine  hundred  and  eight  pages,  pro- 
fu-ely  illustrated,  are  rich  in  physiological,  patholo- 
gical, and  operative  suggestions,  doctrines,  details, 
and  processes;  and  will  prove  a  reliable  resource 
for  information,  both  to  physician  and  sursreon,  in  the 
hour  of  peril. —  Ar.  0.  Med.  and  Surg.  Journal. 

We  are  acquainted  with  no  other  work  wherein 
so  much  good  sense,  sound  principle,  and  practical 
inferences,  stamp  every  page. — American  Lancet. 


ELLIS  (BENJAMIN),  M.D. 
THE   MEDICAL  FORMULARY :   being  a  Collection  of  Prescriptions,  derived 

from  the  writings  and  practice  of  many  of  the  most  eminent  physicians  of  America  and  Europe. 
Together  with  the  usual  Dietetic  Preparations  and  Antidotes  for  Poisons.  To  which  is  added 
an  Appendix,  on  the  Endermic  use  of  Medicines,  and  on  the  use  of  Ether  and  Chloroform.  The 
whole  accompanied  with  a  lew  brief  Pharmaceutic  and  Medical  Observations.  Tenth  edition, 
revised  and  much  extended  by  Robert  P.  Thomas,  M.  D.,  Professor  of  Materia  Medica  in  the 
Philadelphia  College  of  Pharmacy.  In  one  neat  octavo  volume,  extra  cloth,  of  <!9fj  pages.  (Lately 
Issued.)    81  75. 

After  an  examination  of  the  new  matter  and  the  i  It  will  prove  particularly  useful  to  students  and 
alterations,  we  believe  the  reputation  of  the  work  young  practitioners,  as  the  most  important  prescrip- 
built  up  by  the  author,  and  the  late  distinguished  !  tions  employed  in  modern  practice,  which  lie  scat- 
editor,  will  continue  to  flourish  under  the  auspices  tered  through  our  medical  literature,  are  here  col- 
of  the  present  editor,  who  has  the  industry  and  accu-  lected  and  conveniently  arranged  for  reference. — 
racy,  and,  we  would  say,  conscientiousness  requi-  Charleston  Med.  Journal  and  Review. 
site  for  the  responsible  task. — Am.  Jour,  of  P harm. 


FOWNES  (GEORGE),   PH.  D.,  &c. 
ELEMENTARY    CHEMISTRY;    Theoretical  and  Practical.     With  numerous 

illustrations.     Edited,  with  Additions,  by  Robert  Bridges,  M.  D.     In  one  large  royal  12mo. 


volume,  of  over  5fi0  pages,  with  181  wood-cuts. 

We  know  of  no  better  text-book,  especially  in  the 
difficult  department  of  organic  chemistry,  upon 
which  it  is  particularly  full  and  satisfactory.  We 
would  recommend  it  to  preceptors  as  a  capital 
"  office  book"  for  their  students  who  are  beginners 
in  Chemistry.  It  is  copiously  illustrated  with  ex- 
cellent, wood-cuts,  and  altogether  admirably  "got 
up." — iV  J.  Medical  Reporter. 

A  standard  manual,  which  has  long  enjoyed  the 
reputation  of  embodying  much  knowledge  in  a  small 
space.  The  author  has  achieved  the  difficult  task  of 
condensation  with  masterly  tact.  His  book  is  con- 
cise without  being  dry,  and  brief  without  being  too 
dogma  t  ical  or  general. —  Virginia  Med.  and  Surgical 
Journal. 


In  leather,  $1  50;  extra  cloth,  $1  35. 

The  work  of  Dr.  Fownes  has  long  been  before 
the  public,  and  its  merits  have  been  fully  appreci- 
ated as  the  best  text-book  on  chemistry  now  in 
existence.  We  do  not,  of  course,  place  it  in  a  rank 
superior  to  the  works  of  Brande,  Graham,  Turner, 
Gregory,  or  Gmelin,  but  we  say  that,  as  a  work 
for  students,  it  is  preferable  to  any  of 'them. — Lon- 
don Journal  of  Med  trine. 

A  work  well  adapted  to  the  wants  of  the  student. 
It  is  an  excellent  exposition  of  the  chief  doctrines 
and  facts  of  modern  chemistry.  The  size  of  the  work, 
and  still  more  the  condensed  yet  perspicuous  style 
in  which  it  is  written,  absolve  it  from  the  charges 
very  properly  urged  against  most  manuals  termed 
popular. — Edinburgh  Journal  of  Medical  Science. 


FISKE  FUND   PRIZE  ESSAYS. 
THE  EFFECTS  OF  CLIMATE  ON  TUBERCULOUS  DISEASE.    By  Edwin 
Lee,  M.  R.  C.  S.,  London,  and  THE  INFLUENCE  OF  PREGNANCY  ON  THE  DEVELOP- 
MENT OF  TUBERCLES.     By  Edward  Warren,  M.  D.,  of  Edenton,  N.  C.     Together  in 
one  neat  octavo  volume,  extra  cloth.     $1  00.     (Just  Ready.) 


FERGUSSON   (WILLIAM),  F.  R.  S., 

Professor  of  Surgery  in  King's   College,  London,  &c. 

A  SYSTEM  OF  PRACTICAL  SURGERY.     Fourth  American,  from  the  third 

and  enlarged  London  edition.     In  one  large  and  beautifully  printed  octavo  volume,  of  about  700 
pages,  with  393  handsome  illustrations,  leather.     $3  00. 

No  work  was  ever   written  which   more   nearly  I      The  addition  of  many  new  pages  makes  this  work 
Comprehended  the    necessities   irf    the   student   anil  |  more  than  ever  indispensable  to  thestudentand  prae- 
practitioner,  and  was   more   carefully  arranged    to  j  titioner. — Ranking's  Abstract. 
that  single  purpose  than  this. — N.  Y.  Med.  Journal.  \ 


AND    SCIENTIFIC    PUBLICATIONS. 


15 


FLINT  (AUSTIN),  M.   D., 

Professor  of  the  Theory  and  Practice  of  Medicine  in  the  University  of  Louisville,  &c. 

(An  Important  New  Work.'] 

PHYSICAL  EXPLORATION  AND  DIAGNOSIS  OP  DISEASES  APFECT- 

ING  THE  RESPIRATORY  ORGAXS.      In  one  large  and  handsome  octavo  volume,  extra 
cloth,  636  pages.     $3  00. 


We  can  only  state  our  general  impression  of  the 
high  value  of  this  work,  and  cordially  recommend 
it  to  all.  We  regard  it,  in  point  both  of  Arrangement 
and  of  the  marked  ability  of  its  treatment  of  the  sub- 
jects, as  destined  to  take  the  first  rank  in  works  of 
this  class.  So  far  asour  information  extends,  it  has 
at  present  no  equal.  To  the  practitioner,  as  well  as 
the  student,  it  will  be  invaluable  in  clearing  up  the 
diagnosis  of  doubtful  cases,  and  in  shedding  light 
upon  difficult  phenomena. — Buffalo  Med.  Journal. 

This  is  the  most  elaborate  work  devoted  exclu- 
sively to  the  physical  exploration  of  diseases  of  the 
lungs,  with  which  we  are  acquainted  in  the  English 
language.  From  the  high  standing  of  the  author  as 
a  clinical  teacher,  and  his  known  devotion,  during 
many  years,  to  the  study  of  thoracic  diseases  much 
was  to  be  expected  from  the  announcement  of  his 
determination  to  embody  in  the  form  of  a  treatise, 


the  results  of  his  study  and  experience.  These  ex- 
pectations we  are  confident  will  not  be  disappointed. 
For  our  own  part,  we  have  been  favorably  impressed 
by  a  perusal  of  the  book,  and  heartily  recommend  it 
to  all  who  are  desirous  of  acquiring  a  thorough  ac- 
quaintance with  the  means  of  exploring  the  condi- 
tions of  the  respiratory  organs  by  means  of  auscul- 
tation and  percussion.  —  Boston  Med.  and  Surg. 
Journal. 

A.  work  of  original  observation  of  the  highest  merit. 
We  recommend  the  treatise  to  every  one  who  wishes 
to  become  a  correct  auscultator.  Based  to  a  very 
large  extent  upon  cases  numerically  examined,  it 
carries  the  evidtnce  of  careful  studv  and  discrimina- 
tion UDOn  every  page.  It  does  credit  to  the  author, 
and,  through  him,  to  the  profession  in  this  country. 
It  is,  what  we  cannot  call  every  book  upon  auscul- 
tation, a  readable  book. — Am.  Jour.  Med.  Sciences. 


NOW  COMPLETE, 

GRAHAM   (THOMAS),   F.  R.  S., 

THE  ELEMENTS   OF   INORGANIC   CHEMISTRY,  including  the  Applica- 

tions  of  the  Science  in  the  Arts.   New  and  much  enlarged  edition,  by  Henry  Watts  and  Robert 

Bridges,  M.  D.     Complete  in  one  large  and  handsome  octavo  volume,  of  over  800  very  large 

pages,  with  two  hundred  and  thirty-two  wood-cuts,  extra  cloth.     $1  00. 

#*%.  Part  II.,  completing  the  work  from  p.  431  to  end,  with  Index,  Title  Matter,  &c,  may  be 
had  separate,  cloth  backs  and  paper  sides.     Price  S2  50. 

The  long  delay  which  has  intervened  since  the  appearance  of  the  first  portion  of  this  work,  has 
rendered  necessary  an  Appendix,  embodying  the  numerous  and  important  investigations  and  dis- 
coveries of  the  last  few  years  in  the  subjects  contained  in  Part  I.  This  occupies  a  large  portion 
of  Part  II.,  and  will  be  found  to  present  a  complete  abstract  of  the  most  recent  researches  in  the 
general  principles  of  the  science,  as  well  as  all  details  necessary  to  bring  the  whole  work  thoroughly 
up  to  the  present  time  in  all  departments  of  Inorganic  Chemistry. 

The  great  reputation  which  this  work  has  enjoyed  since  its  first  appearance,  and  its  recognized 
position  in  the  front  rank  of  scientific  treatises,  render  eulogy  unnecessary  to  secure  for  it  imme- 
diate  attention  on  the  part  of  those  desiring  to  procure  a  complete  exposition  of  chemical  facts  and 
principles,  either  as  an  introduction  to  the  subject  for  the  student,  or  as  a  work  lor  daily  reference 
by  the  practical  chemist. 

Gentlemen  desirous  of  completing  their  copies  of  the  work  are  requested  to  apply  for  Part  II. 
without  delay.     It  will  be  sent  by  mail,  prepaid,  on  receipt  of  the  amount,  82  50. 


It  is  a  very  acceptable  addition  to  the  library  of 
standard  books  of  every  chemical  student.  Mr. 
Watts. well  known  as  the  translator  of  the  Cavendish 


topics  there  discussed,  that  great  progress  lias  been 
made  in  the  interval,  both  in  chemical  physics  and 
in  general  inorganic  chemistry.     Noreader  ofEng- 


Society  edition  of  Gmelin's  Chemistry,  has  made  in  '  lish  works  on  this  science  can  afford  to  be  without 
the  supplement  an  able  resume  of  the  progress  of  j  thisedition  of  Prof.  Graham's  Elements.— Silltmaa  t 
the  science  since  the  publication  of  the  firstvolume.    Journal,  March,  1853. 
It  is  plain  from  the  number  and  importance  of  the  I 

GRIFFITH  (ROBERT   E.),   M.  D.,  &.c. 

A  UNIVERSAL  FORMULARY,  containing  the  methods  of  Preparing  and  Ad- 
ministering Officinal  and  other  Medicines.  The  whole  adapted  to  Physicians  and  Pharmaceu- 
tists. Second  Edition,  thoroughly  revised,  with  numerous  additions,  by  Robert  P.  Thomas, 
M.  D.,  Professor  of  Materia  Medica  in  the  Philadelphia  College  of  Pharmacy.  In  one  larpe  and 
handsome  octavo  volume,  extra  cloth,  of  650  pages,  double  columns.  (Just  Issued.)  S3  00;  or 
bound  in  sheep,  $3  25. 
It  was  a  work  requiring  much  perseverance,  and  ' 

when  published  was  looked  upon  as  by  far  the  best  | 

work  of  its  kind  that  had  issued  from  the  American 

press.     Prof  Thomas  has  certainly  "improved."  as 

well  as  added   othis  Formulary,  and  has  rendered  it 

addiiionally  deserving  of  the  confidence  of  pharma- 
ceutists and  physicians.— Am.  Journal  of  Pharmacy. 
We  are  happy  to  announce  a  new  and  improved 

edition  of  this,  one  of  the  most  valuable  and  useful 

works  that  have  emanated  from  an  American  pen.; 

It  would  do  credit  to  any  country,  and  will  be  found 

of  daily  usefulness  to  practitioners  of  medicine;  it  is 

better  adapted  to  their  purposes  than  the  dispensato- 
ries.— Southern  Med.  and  Surg.  Journal. 


nistering  medicines  that  can  be  desired  by  the  physi- 
cian and  pharmaceutist. —  Western  L<u<r.  | 

The  amount  of  useful,  every-day  matter,  for  a  prac- 
ticing physician,  is  really  immense. — Boston  Med 
and  Surg.  Journal. 

We  predict  a  great  sale  for  this  work,  and  we  espe- 
eiallv  recommend  it  to  all  medical  teachers.—  Rich- 
mond  Stethoscope. 

This  edition  of  Or.  Griffith'*  work  has  been  greatly 
improved  by  the  revision  and  amp  -  of  Or. 

Thomas,  and  is  now.  we  believe,  one  of  the  most 
complete  works  of  its  kind  ill  any  language.  The 
additions  amount  to   about  seventy    p  d    no 

effort  has  been  spared  lo  include  in  them  all  the  re- 
It  is  one  of  the  most  useful  books  a  country  practi-    ,.,.,,,    improvements   which    have  been  published  in 
tioner  can  possibly  have  in  his  possession. — Mtdica,    medical  journals,  and  systematic  treatises      \  work 
Chronicle.  of  this  kind  appear-  ip  us  indispensable  lo  the  physi- 

This  is  a  work  of  six  hundred  and  fifty  one  page,     cian,  and  there  is  none  we  can  more  cordially  recora- 
embracing  all  on  the  subject  of  preparing  and  admi     mend.- IV.  Y.  Journal  of  Medtcxne. 

BY   THE  SAME   AUTHOR. 

MEDICAL  BOTANY;  or,  a  Description  of  all  the  more  important  Plants  used 

in  Medicine,  and  of  their  Properties,  Uses,  and  Modes  of  Administration.     In  one  large  octavo 
volume,  extra  cloth,  of  704  pages,  handsomely  printed,  with  nearly  3u0  illustrations  on  wood,  *J  00. 


1G 


RLANCHAKD    &    LEA'8   MEDICAL 


GROSS  (SAMUEL  D.),    M.  D., 
ProfoMOI  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia,  ice. 

New  Edition  (Now  Ready.) 

ELEMENTS  OF  PATHOLOGICAL  ANATOMY.    Third  edition,  thoroughly 

revised  and  greatly  improved.    In  one  large  and  irery  handsome  octavo  volume,  with  about  three 

bundled  and  filly  beautiful  illustrations,  of  which  a  large  number  are  from  original  drawings. 

Price  m  extra  cloth,  -l  75;  leather,  raised  bands,  $5  25. 

The  very  rapid  advances  in  the  Science  of  Pathological  Anatomy  during  the  last  few  years  have 
rendere  essential  a  thorough  modification  of  this  work,  with  a  view  of  making  it  a  correct  expo- 
nent oi  the  present  stale  of  the  subject.     The  very  careful  manner  in  which  this  task  lias  been 

:uted,  and  the  a tnt  of  alteration  which  it  has lergone,  have  enabled  the  author  to  say  thai 

iny  changes  and  improvement-  now  introduced,  the  work  may  lie  regarded  almost  as 
a  new  treatise,1' 'while  the  efforts  of  the  author  have  been  seconded  as  regards  the  mechanical 
execution  of  the  volume,  rendering  it  one  of  the  handsomest  productions  of  the  American  press. 
rge  n  umber  of  new  and  beautiful  original  illustrations  have  been  introduced,  and  the  work, 
ii  j<  hoped,  will  fully  maintain  the  reputation  hitherto  enjoyed  by  it  of  a  complete  and  practical  ex- 
ion  of  its  difJBcult  and  important  subject. 

We  moat  sincerely  congratulate  the  author  on  the  ,  We  have  been  favorably  impressed  with  the  gene- 
snccessl  ill  manner  in  which  he  has  accomplished  lus  ral  manner  in  winch  Dr.  Gross  has  executed  his  task 
proposed  object.  His  hook  is  most  admirably  cal-  of  affording  a  comprehensive  digest  of  the  present 
cnlaled  to  fill  up  a  blank  which  has  long  been  felt  to  state  of  the  literature  of  Pathological  Anatomy, and 
exist  in  tins  department  of  medical  literature,  and  have  much  pleasure  in  recommending  his  work  to 
as  auch  must  become  very  widely  circulated  amongst  our  readers,  as  we  believe  one  well  deserving  of 
all  classes  of  the  profession.  —  Dublin  Quarterly  dilisent  perusal  and  careful  study.— Montreal  Med. 
Journ.  of  Med.  Science,  Nov.  1857.  Citron.,  Sept.  li.37. 

BY   THE   SAME   AUTHOR. 

A   PRACTICAL    TREATISE   ON   THE    DISEASES,    INJURIES,   AND 

.MALFORMATIONS  OF  THE  URINARY  BLADDER,  THE  PROSTATE  GLAND,  AND 
THE  URETHRA.  Second  Edition,  revised  and  much  enlarged,  with  one  hundred  and  eighty- 
four  illustrations.  In  one  large  and  very  handsome  octavo  volume,  of  over  nine  hundred  pages. 
In  leather,  raised  bands,  $5  25-;  extra  cloth,  $4  75. 


A  volume  replete  with  truths  and  principles  of  the 
utmost  value  in  the  investigation  of  these  diseases. — 

American  Medical  Journal. 

On  the  appearance  of  the  first  edition  of  this  work, 
the  leading  English  medical  review  predicted  that  it 
would  have  a  "  permanent  place  in  the  literature  of 
surgery  worthy  to  rank  with  the  best  works  of  the 
present  age."  This  prediction  has  been  amply  ful- 
filled Dr.  Gross's  treatise  has  been  found  to  sup- 
ply completely  the  want  which  has  been  felt  ever 
since  the  elevation  of  surgery  to  the  rank  of  a  science, 
of  a  good  practical  treatise  on  the  diseases  of  the 
bladder  and  its  accessory  organs.  Philosophical  in 
its  design,  methodical  in  its  arrangement,  ample  and 


sound  in  its  practical  details,  it  may  in  truth  be  said 
to  leave  scarcely  anything  to  be  desired  on  so  im- 
portant a  subject,  and  with  the  additions  and  modi- 
fications resulting  from  future  discoveries  and  im- 
provements, it  will  probably  remain  one  of  the  most 
valuable  works  on  this  subject  so  long  as  the  science 
of  medicine  shall  exist. — Boston  Med.  and  Surg. 
Journal. 

Whoever  will  peruse  the  vast  amount  of  valuable 
practical  information  it  contains,  and  which  we 
have  been  unable  even  to  notice,  will,  we  think, 
agree  with  us,  that  there  is  no  work  in  the  English 
language  which  can  make  any  just  pretensions  to 
be  its  equal. — N.  Y.  Journal  of  Medicine. 


BY  THE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  ON  FOREIGN  BODIES  IN  THE  AIR-PAS- 

SAGES.     In  one  handsome  octavo  volume,  extra  cloth,  with  illustrations,    pp.  468.     $2  75. 

conclude  by  recommending  it  to  our  readers,  fully 
persuaded  that  its  perusal  will  afford  them  much 
practical  information  well  conveyed,  evidently  de- 
rived from  considerable  experience  and  deduced  from 


A  very  elaborate  work.  It  is  a  complete  summary 
of  the  whole  subject,  and  will  be  a  useful  book  of 
reference. — British  and  Foreign  Medico-Cltirurg. 
ift  vii  to. 

A  highly  valuable  book  of  reference  on  a  most  im- 
portant subject  in   the  practice  of  medicine.     We 


an   ample   collection 
Journal,  May,  1655. 


of  facts.  —  Dublin  Quarterly 


BY  the  same  author.     {Preparing.) 

A  SYSTEM  OF  SURGERY;  Diagnostic,  Pathological,  Therapeutic,  and  Opera- 
tive.    With  very  numerous  engravings  on  wood. 


GLUGE  (GOTTLIEB),   M .  D., 
Professor  of  Physiology  and  Pathological  Anatomy  in  the  University  of  Brussels,  &c. 

AN  ATLAS   OF    PATHOLOGICAL   HISTOLOGY.     Translated,  with  Notes 

and  Additions,  by  Joseph  Leidy,  M.  D.,  Professor  of  Anatomy  in  the  University  of  Pennsylva- 
nia. In  one  volume,  very  larg-e  imperial  quarto,  extra  cloth,  with  320  figures,  plain  and  colored, 
on  twelve  copperplates.     $5  00. 


GARDNER'S  MEDICAL  CHEMISTRY,  for  the 
use  .,i  S:  nihil  ts  and  the  Profession.  In  one  royal 
l2mo.  vol.,  ex.  cloth,  pp.  396,  with  illustrations. 

!?1    (10. 

HARRISON'S  ESSAY  TOWARDS  A  CORRECT 
THEORY  Of  THE  NERVOUS  SYSTEM.    In 

one  octavo  volume,  leather,  2y_>  pages.    $1  50. 


HUGHES'  CLINICAL  INTRODUCTION  TO 
THE  PRACTICE  OF  AUSCULTATION  AND 
OTHER  MODES  OF  PHYSICAL  DIAGNOSIS, 
IN  DISEASES  OF  THE  LUNGS  AND  HEART. 
Second  American,  from  the  second  London  edition. 
1  vol.  royal  l'iino.,  ex.  cloth,  pp.  304.     $1  00. 

HUNTER'S  COMPLETE  WORKS,  in  1  vols. 
8vo.,  leather,  with  plates.     S10. 


AND    SCIENTIFIC    PUBLICATIONS. 


17 


HOBLYN   (RICHARD  D.),  M .  D. 

A  DICTIONARY  OF  THE  TERMS  USED  IN  MEDICINE  AND  •  THE 

COLLATERAL  SCIENCES.  By  Richard  D.  Hoblyn,  A.  M,  &rc.  A  new  American  edi- 
tion. Revised,  with  numerous  Additions,  by  Isaac  Hays,  M.  D.,  editor  of  the  "American 
Journal  of  the  Medical  Sciences."  In  one  large  royal  12mo.  volume,  leather,  of  over  000  double 
columned  pages.     {Just  Issued,  1856.)     $1  50. 

If  the  frequency  with  which  we  have  referred  to    nor  desire  to  procure  a  larger  work.-    American 
this  volume  since  its  reception  from  the  publisher, 
two  or  three  weeks  ago,  be  uny  criterion  for  the 


nor  desire 
Lancet. 


Hoblyn  lias  always  been  a  favorite  dictionary,  and 


future,  the  binding  will  soon  have  to  be  renewed,  even  i  in  its  present  enlarged  and  improved  form  will  give 
with  careful  handling.  We  find  that  Dr.  Hays  lias 
done  the  profession  great  service  by  his  careful  and 
industrious  labors.  The  Dictionary  has  thus  become 
eminently  suited  to  our  medical  brethren  in  this 
country.  The  additions  by  Dr.  Hays  are  in  brackets, 
and  we  believe  there  is  not  a  single  page  but  bears 
these  insignia;  in  every  instance  which  we  have  thus 
far  noticed,  the  additions  are  really  needed  and  ex- 
ceedingly valuable.  We  heartily  commend  the  work 
to  all  who  wish  to  be  au  courant  in  medical  termi- 
nology.— Boston,  Med.  and  Surg.  Journal. 

To  both  practitioner  and  student,  we  recommend 
this  dictionary  as  being  convenient  in  size,  accurate 
in  definition,  and  sufficiently  full  and  complete  for 
ordinary  consultation. — Charleston  Med.  Journ.  and 
Review. 


Admirably  calculated  to  meet  the  wants  of  the 
practitioner  or  student,  who  has  neither  the  means 


greater  satisfaction  than  ever.  The  American  editor, 
Dr.  Hays,  has  made  many  very  valuable  additions. 
— N.J.  Med.  Rejiorter. 

To  supply  the  want  of  the  medical  reader  arising 
from  this  cause,  we  know  of  no  dictionary  better 
arranged  and  adapted  than  the  one  bearing  the  above 
title.  It  is  not  encumbered  with  the  obsolete  terms 
of  a  bygone  age,  but  it  contains  all  that  are  now  in 
use;  embracing  every  department  of  medical  science 
down  to  the  very  latest  date.  The  volume  is  of  a 
convenient  size  to  be  used  by  the  medical  student, 
and  yet  large  enough  to  make  a  respectable  appear- 
ance in  the  library  of  a  physician. — Western  Lancet. 

Hoblyn's  Dictionary  has  long  been  a  favorite  with 
us.  It  is  the  best  book  of  definitions  we  have,  and 
ought  always  to  be  upon  the  student's  table. — 
Southern  Med.  and  Surg.  Journal. 


HOLLAND  (SIR    HENRY),    BART.,    M.D..F.  R.S., 

Physician  in  Ordinary  to  the  Queen  of  England,  &c. 

MEDICAL  NOTES  AND  REFLECTIONS.     From  the  third  London  edition. 

In  one  handsome  octavo  volume,  extra  cloth.     (Now  Ready.)     $3  00. 

As  the  work  of  a  thoughtful  and  observant  physician,  embodying  the  results  of  forty  years'  ac- 
tive professional  experience,  on  topics  of  the  highest  interest,  this  volume  is  commended  to  the 
American  practitioner  as  well  worthy  his  attention.  Few  will  rise  from  its  perusal  without  feel- 
ing their  convictions  strengthened,  and  armed  with  new  weapons  for  the  daily  struggle  with 
disease. 


HABERSHON  (S.  O.),  M .  D., 
Assistant  Physician  to  and  Lecturer  on  Materia  Medica  and  Therapeutics  at  Guy's  Hospital,  &c. 

PATHOLOGICAL   AND   PRACTICAL  OBSERVATIONS  ON  DISK  \SES 

OF  THE  ALIMENTARY  CANAL,  OESOPHAGUS,  STOMACH,  CiECUM,  AND  INTES- 
TINES.    With  illustrations  on  wood.     In  one  handsome  octavo  volume.     (KepuOlu/Mig  vn  tM 

Medical  News  and  Library  for  1858.) 


HORNER  (WILLIAM  E.),  M .  D., 
Professor  of  Anatomy  in  the  University  of  Pennsylvania. 

SPECIAL    ANATOMY    AND    HISTOLOGY.     Eighth  edition.     Extensively 

revised  and  modified.      In  two  large  octavo  volumes,  extra  cloth,  of  more  than  one  thousand 
pages,  handsomely  printed,  with  over  three  hundred  illustrations. 


m  oo. 


HAMILTON   (FRANK    H.),    M.   D., 

Professor  of  Surgery,  in  Buffalo  Medical  College,  <lfcc. 

A  TREATISE  ON  FRACTURES  AND  DISLOCATIONS.     In  one  handsome 

octavo  volume,  with  numerous  illustrations.     (Preparing.) 


JONES  (T.   WHARTON),   F.  R.  S., 

Professor  of  Ophthalmic  Medicine  and  Surgery  in  University  College,  London,  &c. 

THE  PRINCIPLES  AND  PRACTICE  OF   OPHTHALMIC    MEDICINE 

AND  SUIIGERY.  With  one  hundred  and  ten  illustrations.  Second  American  from  the  Becond 
and  revised  London  edition,  with  additions  by  Edwahd  HaRTSHOKNB,  M.  Dm  Surgeon  to  \V  ,ll> 
Hospital,  fee.     In  one  large,  handsome  royal  12mo.  volume,  extra  cloth,  of  500  pages.     $1  o0. 

We  are  confident  that  the  reader  will  find,  on 
perusal,  that  the  execution  of  the  work  amply  fulfils 
the  promise  of  the  preface,  and  sustains,  in  every 
point,  the  already  high  reputation  of  the  author  as 
an  ophthalmic  surgeon  as  well  as  a  physiologist 
and  pathologist.  The  book  is  evidently  the  result 
of  much  labor  and  research,  and  has  been  writti  D 
with  the  greatest  care  and  attention;  it  possesses 
that  best,  quality  which  a  general  work,  like  a  sys- 
tem or  manual  can  show,  viz  :  the  quality  of  having 
all  the  materials  whencesoever  derived,  so  thorough- 


ly wrought  up.  and  digested  in  the  author's  mind, 

as  to  come  forth  with  the  freshness  ami  impressive- 

,1  production,     w  e  entertain  little 

doubf  thai  tins  book  will  become  what  its  author 

)  oped  it  might  become,  a  manual  for  daily  reference 

and  consultation  by  the  student  and  the  general  prac- 
titioner.   The  workis  marked  by  that  correctness, 

clearness,  ai  ■ "  style  which  distinguish 

all  the  productions  of  the  learned  author.— British 
and  For.  Med.  Review. 


!» 


HLANCHAKD  &  LEA'S  MEDICAL 


JONES  (C.   HAND  FIELD),   F.  R.  S.,  &.   EDWARD   H.   SI  EV  EKING,    M.D., 
Assistant  Physicians  and  Lecturers  in  St.  Mary's  Hospital,  London. 

A  MANUAL  OF  PATHOLOGICAL   ANATOMY.     First  American  Edition, 

Kevi-cd.     With  throe  hundred  ami  ninety-seven  handsome  wood  engravings.     In  one  large  and 
beautiful  octavo  volume  of  nearly  750  pages,  leather.     S3  75. 

present  condition  of  pathological  anatomy.     In  this 


As  a  concise  text-book-.  Containing,  in  a  condensed 
form,  a  complete  outline  of  what  is  known  in  the 
domain  of  Pathological  Anatomy,  it  is  perhaps  the 
beat  work  in  the  English,  language.     Its  great  merit 

consists  in  iik  completeness  and  brevity,  and  in  this 
respect  it  supplies  a  great  desideratum  in  our  lite- 
rature. Heretofore  the  student  of  pathology  was 
obliged  toglean  from  a  great  number  of  monographs. 
and  the  field  was  so  extensive  that  but  few  cultivated 
n  with  any  degree  of  success.  As  a  simple  work 
of  reference,  therefore,  it  is  of  great  value  to  the 
student  of  pathological  anatomy,  and  should  be  in 
every  physician's  library.—  Western  Lancet. 

In  offering  the  above  titled  work  to  the  public,  the 
authors  have  not  attempted  to  intrude  new  views  on 
their  professional  brethren,  but  simply  to  lay  before 
them,  what  has  long  been  wanted,  an  outline  of  the 


they  have  been  completely  successful.  The  work  is 
one  of  the  best  compilations  which  we  have  ever 
perused. — Charleston  Medical  Journal  and  Review. 

We  urge  upon  our  readers  and  the  profession  gene- 
rally the  importance  of  informing  themselves  in  re- 
gard to  modern  views  of  pathology,  and  recommend 
to  them  to  procure  the  work  before  us  as  the  best 
means  of  obtaining  this  information. — Stethoscope. 

From  the  casual  examination  we  have  given  we 
are  inclined  to  regard  it  as  a  text-book,  plain,  ra- 
tional, and  intelligible,  such  a  book  as  the  practical 
man  needs  for  daily  reference.  For  this  reason  it 
will  be  likely  to  be  largely  useful,  as  it  suits  itself 
to  those  busy  men  who  have  little  time  for  minute 
investigation,  and  prefer  a  summary  to  an  elaborate 
tieatise. — Buffalo  Medical  Journal. 


KIRKES  (WILLIAM   SENHOUSE),    M.  D., 

Demonstrator  of  Morbid  Anatomy  at  St.  Bartholomew's  Hospital,  &c. 

A    MANUAL    OF    PHYSIOLOGY.      A  now  American,  from  the   third  and 

improved  London  edition.     With  two  hundred  illustrations.     In  one  large  and  handsome  royal 
12mo.  volume,  leather,     pp.  580.     $2  00.     (Now  Ready,  1857.) 

In  again  passing  this  work  through  his  hands,  the  author  has  endeavored  to  render  it  a  correct 
exposition  of  the  present  condition  of  the  science,  making  such  alterations  and  additions  as  have 
been  dictated  by  further  experience,  or  as  the  progress  of  investigation  has  rendered  desirable.  In 
every  point  of  mechanical  execution  the  publishers  have  sought  to  make  it  superior  to  former  edi- 
tions, and  at  the  very  low  price  at  which  it  is  offered,  it  will  be  found  one  of  the  handsomest  and 
cheapest  volumes  before  the  profession. 

In  making  these  improvements,  care  has  been  exercised  not  unduly  to  increase  its  size,  thus 
maintaining  its  distinctive  characteristic  of  presenting  within  a  moderate  compass  a  clear  and  con- 
nected view  of  its  subjects,  sufficient  for  the  wants  of  the  student. 

This  is  a  new  and  very  much  improved  edition  of  j      One  of  the  very  best  handbooks  of  Physiology  we 


Dr.  Kirkes'  well-known  Handbook  of  Physiology. 
Originally  constructed  on  the  basis  of  the  admirable 
treatise  of  Miller,  it  has  in  successive  editions  de- 
veloped itself  into  an  almost  original  work,  though 
no  change  has  been  made  in  the  plan  or  arrangement. 
It  combines  conciseness  with  completeness,  and  is, 
therefore,  admirably  adapted  for  consultation  by  the 
busv  practitioner. — Dublin  Quarterly  Journal  .Feb. 
1857. 

Its  excellence  is  in  its  compactness,  its  clearness, 
and  its  carefully  cited  authorities.  It  is  the  most 
convenient  of  text-books.  These  gentlemen,  Messrs 
Kirkes  and  Paget,  have  really  an  immense  talent  for 
silence,  which  is  not  so  common  or  so  cheap  as  prat- 
ing people  fancy.  They  have  the  gift  of  telling  us 
what  we  want  to  know,  without  thinking  it  neces- 
sary to  tell  us  all  they  know.— Boston  Med  and 
Surg.  Journal,  May  14,  1857. 


possess— presenting  just  such  an  outline  of  the  sci- 
ence, comprising  an  account  of  its  leading  facts  and 
generally  admitted  principles,  as  the  student  requires 
during  his  attendance  upon  a  course  of  lectures,  or 
for  reference  whilst  preparing  for  examination. — 
Am.  Medical  Journal. 

We  need  only  say,  that,  without  entering  into  dis- 
cussions of  unsettled  questions,  it  contains  all  the 
recent  improvements  in  this  department  of  medical 
science.  For  the  student  beginning  this  study,  and 
the  practitioner  who  has  but  leisure  to  refresh  his 
memory,  this  book  is  invaluable,  as  it  contains  all 
that  it  is  important  to  know,  without  special  details, 
which  are  read  with  interest  only  by  those  who 
would  make  a  specialty,  or  desire  to  possess  a  criti1 
cal  knowledge  of  the  subject. — Charleston  Medical 
Journal. 


KNAPP'S  TECHNOLOGY;  or,  Chemistry  applied 
to  the  Arts  and  to  Manufactures.  Edited,  with 
numerous  Notes  and  Additions,  by  Dr.  Edmund 
Ronalds  and  Dr.  Thomas  Richardson.  First 
American  edition,  with  Notes  and  Additions,  by- 
Prof.   Walter  R.  Johnson.      In  two  handsome 


octavo  volumes,  extra  cloth,  with  about 500  wood- 
engravings.    $6  00. 

LALLEMAND  ON  SPERMATORRHOEA 

lated  and  edited  by  Henry  J.  McDocgal 
volume,  octavo,  extra  cloth,  320  pages. 
American  edition.     SI  75. 


Trans- 

In  one 

Second 


LUDLOW  (J.   L.S   M.  D. 
A   MANUAL   OF    EXAMINATIONS   upon   Anatomy,   Physiology,    Surgery, 

Practice  of  Medicine,  Obstetrics,  Materia  Medica,  Chemistry,  Pharmacy,  and  Therapeutics.  To 
which  is  added  a  Medical  Formulary.  Designed  for  Students  of  Medicine  throughout  the  United 
States.  Third  edition,  thoroughly  revised  and  greatly  extended  and  enlarged.  With  three 
hundred  and  seventy  illustrations.  In  one  large  and  handsome  royal  12mo.  volume,  leather,  of 
over  800  closely  printed  pages      (Now  Ready.)    S2  50. 

The  <rreat  popularity  of  this  volume,  and  the  numerous  demands  for  it  during  the  two  years  in  which 
it  has  been  out  of  print,  have  induced  the  author  in  its  revision  to  spare  no  pains  to  render  it  a 
correct  and  accurate  digest  of  the  most  recent  condition  of  all  the  branches  of  medical  science.  In 
many  respects  it  may,  therefore,  be  regarded  rather  as  a  new  book  than  a  new  edition,  an  entire 
section  on  Physiology  having  been  added,  as  also  one  on  Organic  Chemistry,  and  many  portions 
having  been  rewritten.  A  very  complete  series  of  illustrations  has  been  introduced,  and  every 
care  ha*  been  taken  in  the  mechanical  execution  to  render  it  a  convenient  and  satisfactory  book  for 
btudyor  reference. 

The  arrangement  of  the  volume  in  the  form  of  question  and  answer  renders  it  especially  suited 
for  the  office  examination  of  students  and  for  those  preparing  for  graduation. 


We  know  if  no  better  companion  for  the  student 
during  the  hours  spent  in  the  lecture  room,  or  to  re- 
fresh, at  a  glance,  his  memory  of  the  various  topics 


crammed  into  his  head  by  the  various  professors  to 
whom  he  is  compelled  to  listen. —  Western  Lancet, 
May.  1857. 


AND    SCIENTIFIC    PUBLICATIONS.  19 


LEHMANN    (C.  G.) 

PHYSIOLOGICAL    CHEMISTRY.      Translated  from  the   second   edition   by 
George  E.  Day,  M.  D.,  F.R.S.,  &c,  edited  by  R.  E.  Rogeks,  M.  D.,  Professor  of  Chemistry 

in  the  Medical  Department  of  the  University  of  Pennsylvania,  with  illustrations  selected  from 
Funke's  Atlas  of  Physiological  Chemistry,  and  an  Appendix  of  plates.  Complete  in  two  large 
and  handsome  octavo  volumes,  extra  cloth,  containing  1200  pages,  with  nearly  two  hundred  illus- 
trations.    (Just  Issued.)     $6  00. 

This  great  work,  universally  acknowledged  as  the  most  complete  and  authoritative  exposition  of 
the  principles  and  details  ot  Zoochemistry,  in  its  passage  through  the  press,  has  received  from 
Professor  Rogers  such  care  as  was  necessary  to  present  it  in  a  correct  and  reliable  form.  To  such 
a  work  additions  were  deemed  superfluous,  but  several  years  having  elapsed  between  the  appear- 
ance in  Germany  of  the  first  and  last  volume,  the  latter  contained  a  supplement,  embodying  nume- 
rous corrections  and  additions  resulting  from  the  advance  of  the  science.  These  have  all  been  incor- 
porated in  the  text  in  their  appropriate  places,  while  the  subjects  have  been  still  further  elucidated  by 
the  insertion  of  illustrations  from  the  Atlas  of  Dr.  Otto  Funke.  With  the  view  of  supplying  the  student 
with  the  means  of  convenient  comparison,  a  large  number  of  wood-cuts,  from  works  on  kindred 
subjects,  have  also  been  added  in  the  form  of  an  Appendix  of  Plates.  The  work  is,  therefore,  pre- 
sented as  in  every  way  worthy  the  attention  of  all  who  desire  to  be  familiar  with  the  modern  facts 
and  doctrines  of  Physiological  Science. 

The  most  important  contribution  as  yet  made  to  ]  it  treats.— Edinburgh  Monthly  Journal  of  Medical 

Physiological  Chemistry Am.  Journal  Med.  Sci-  I  Science. 

ences,  Jan.  1S56.  Already  well  known  and  appreciated  by  the  scien- 

The  present  volumes  belong  to  the  small  class  of  I  tine  world,  Professor  Lehmann's  great  work  re- 
medical  literature  which  comprises  elaborate  works  quires  no  laudatory  sentences,  as.  uiuler  a  new  garb, 
of  the  highest  order  of  merit.— Montreal  Med.  Chron-  ,  it  is  now  presented  to  us.  The  little  space  at  our 
icle    Jan    1856  I  command  would  ill  suffice  to  set  iorth  even  a  small 

''',',  ,  n_j  „„  fh_  '  portion  of  its  excellences. — Boston  Med.  and  Surg. 

The  work  of  Lehmann   stands  unrivalled  as  the  ,  K  ,   ^        IHSS 

most  comprehensive  book  of  reference  and  informa-     Journal,  uec.  1000. 
tion  extant  on  every  branch  of  the  subject  on  which  I 

BY  THE  SAME  AUTHOR.       (Just  Issued,  1856.) 

MANUAL  OF  CHEMICAL   PHYSIOLOGY.      Translated  from  the  German, 

with  Notes  and  Additions,  by  J.  Chestom  Morris,  M.  D.,  with  an  Introductory  Essay  on  Vital 
Force,  by  Samuel  Jackson,  M.  D.,  Professor  of  the  Institutes  of  Medicine  in  the  University  of 
Pennsylvania.  With  illustrations  on  wood.  In  one  very  handsome  octavo  volume,  extra  cloth, 
of  336'pages.     $2  25._ 

From  Prof.  Jackson's  Introductory  Essay. 

In  adopting  the  handbook  of  Dr.  Lehmann  as  a  manual  of  Organic  Chemistry  for  the  use  of  the 
students  of  the  University,  and  in  recommending  his  original  work  of  Physiological  Chemistry 
for  their  more  mature  studies,  the  high  value  of  his  researches,  and  the  great  weight  of  his  autho- 
rity in  that  important  department  of  medical  science  are  fully  recognized 


The  present  volume  will  be  a  very  convenient  one 
for  students,  as  offering  a  brief  epitome  of  the  more 
elaborate  work,  and  as  containing,  in  a  very  con- 


densed  form,   the  positive  facts   of   Physiological 
Chemistry.— Am.  Journal  Med.  Sciences,  April,  1S56. 


LAWRENCE  (W.),   F.  R.  S.,  &.C. 
A  TREATISE    ON    DISEASES    OF    THE    EYE.     A    new  edition,   edited, 

with  numerous  additions,  and  243  illustrations,  by  Isaac  Hays,  M.  D.,  Surgeon  to  Will's  Hospi- 
tal, &c.  In  one  very  large  and  handsome  octavo  volume,  of  950  pages,  strongly  bound  in  leather 
with  raised  bands.     $5  00. 

This  admirable  treatise-  the  safest  guide  and  most  octavo  pages-  has  enabled  both  author  and  editor  to 
comprehensive  work  of  reference,  which  is  within  do  justice  to  a  1  the  details  of  this  sub  cct,  and  con- 
the  reach  of  the  profession.-S^oscope.  dense  in  this  single  volume  the  present  stateofooi 

v  knowledge  of  the  whole  science  in  this  department, 

This  standard  text-book  on  the  department  of  :  whereby  its  practical  value  cannot  be  "Celled.  We 
which  it  treats,  has  not  been  superseded,  by  any  or  \  heartily  commend  it,  especially  as  a  book  ol  refer- 
all  of  the  numerous  publications  on  the 'subject  !  ence,  indispensable  in  J^^^J^[X-™ 
heretofore  issued.  Nor  with  the  multiplied  improve-  additions  of  the  American  editor  very  greatl .en 
ments  of  Dr.  Hays,  the  American  editor,  is  it  at  all  nance  the  value  of  the  wok,  «hibiting the ^earning 
likely  that  this  great  work  will  cease  to  merit  the    and  experience  of  Dr.  Hays,  in  the  hg I  vl   en  he 

confidence  and  preference  of  students  or  practition-  ,  ought  to  be  held,  as  "tart^uthontt  on  all  sab- 
ers.    Its  ample  extent-nearly  one  thousand  large  ;  jects  appertaining  to  this  specialty  .-If.  Y.  Mtd.  Uaz. 

LARDNER  (DIONYSIUS),   D.  C.  L.,  &.c. 
HANDBOOKS    OF    NATURAL    PHILOSOPHY    AND    ASTRONOMY. 

Revised,  with  numerous  Additions,  by  the  American  editor.  First  Course,  conta,,,,,,,^. Mecha- 
nics, Hydrostatics,  Hydraulics,  Pneumatics,  Sound,  and  Optics.  In  one  ^/^^mo. 
volume,  of  750  pages,  with  424  wood-cuts.  $1  75.  Second  Corns*  containing  Heat,  E h  ru-  >t>  , 
Magnetism,  and  Galvanism,  one  volume,  large  royal  12mo.,  of  450  pages,  with  250  illustrations. 
61  25.  Third  Course  (now  ready).,  containing  Meteorology  and  Astronomy,  in  one  large  volume, 
royal  12mo.  of  nearly  800  pages,  with  37  plates  and  200  wood-cuts.     $2  00. 

LAYCOCK  (THOMAS),    M .  D.,    F.  R.  S.  E., 

Professor  of  Practical  and  Clinical  Medicine  in  the  University  of  Edinburgh,  &c. 

LECTURES    ON   THE    PRINCIPLES    AND   METHODS    OF    MEDICAL 

ORSFRVATION  AND  RESEARCH.  For  the  Use  of  Advanced  Students  and  Junior  Jrac- 
SSiers    1  onTvery  neat  foyal  12mo.  volume,  extra  cloth.  Price  SI  00.  (Just  Published,  1S57.) 


20 


BLANCH  .\  i;  I)    &    LEA'S    MEDICAL 


LA  ROCHE  (R.),  M.  D.,  &c. 
3TBLL0W  FEVER,  considered  in  its  Historical,  Pathological,  Etiological,  and 
Therapeutical  Relations.  Including  a  Sketch  of  the  Disease  as  it  has  occurred  in  Philadelphia 
from  1699 to  1854,  with  an  examination oi  Hie  connections  between  it  and  the  lovers  known  under 
the  same  name  in  other  parts  of  temperate  as  well  as  in  tropical  regions.  In  two  large  and 
handsome  octavo  volumes  of  nearly  1500  pages,  extra  cloth.    $7  00. 

arduous  research  and  careful  study,  and  the  result 
is  such  as  will  reflect  the  highest  honor  npon  tlLft 
author  and  our  country.— Southern  Med.  and  Surg. 


From  Professor  S.  II-  Dirk  son.  Charleston,  S.  C, 
mbi  r  18,  1855. 

A  irtonpmenl  of  intelligent  and  well  applied  re- 

■earch,  almost  without  example.    It  is,  indeed,  in 

library,  ami  is  destined  to  constitute 

the  special  resort  as  n  book   of  reference,  in   the 

subject  of  which  it  treats,  to  all  future  tfme. 

We  have  not  lime  at  present,  engaged  as  we  nre, 
by  da*  and  by  night,  in  the  work  of  combating  this 
very  disease,  now  prevailing  in  our  city,  to  do  mure 
than  five  this  cursory  notice  of  what  we  consider 
us  undoubtedly  the  must  able  and  erudite  medical 
publication  our  country  has  yet  produced  But  in 
\  i.  v.-  ol  the  startling  fact,  that  this,  the  most  malig- 
nant and  unmanageable  disease  of  modern  times, 
has  for  several  rears  been  prevailing  in  our  country 
toa  greater  extent  than  ever  before;  that  it  is  no 
longer  confined  to  either  large  or  small  cities,  but 
penetrates  country  villages)  plantations,  and  farm- 
houses; that  it  is  treated  witli  scarcely  better  suc- 
cess now  than  thirty  or  forty  years  agoi  that  there 
is  vast  mischief  done  by  ignorant  pretenders  to  know- 
ledge in  regard  to  the  disease,  and  in  view  of  the  pro- 
bability that  a  majority  of  southern  physicians  will 
be  called  upon  to  treat  the  disease,  we  trust  that  this 
able  and  comprehensive  treatise  will  be  very  gene- 
rally read  in   the  south. — Memphis  Med.  Recorder. 

This  is  decidedly  the  great  American  medical  work 
Of  the  day — a  full,  complete,  and  systematic  treatise, 
unequalled  by  any  other  upon  the  all-important  sub- 
jectof  Yellow  Fever.  The  laborious,  indefatigable, 
and  learned  author  has  devoted  to  it  many  years  of 


Journal. 

The  genius  and  scholarship  of  thisgreat  physician 
could  not  have  been  better  employed  than'  in  the 
erect  i, mi  of  tins  towering  monument  to  his  own  fame, 
and  to  the  glory  of  the  medical  literature  of  his  own 
country.  It  is  destined  to  remain  the  great  autho- 
rity upon  the  subject  of  Yellow  Fever.  The  stud,  at 
and  physician  will  find  in  these  volumes  a  risumt 
of  the  sum  total  Of  the  knowledge  of  the  world  upon 
the  a  win  I  scourge  which  they  so  elaborately  discuss. 
The  style  is  so  soft  and  so  pure  as  to  refresh  and  in- 
vigorate the  mind  while  absorbing  the  thoughts  of 
the  gifted  author,  while  the  publishers  have  suc- 
ceeded in  bringing  the  externals  into  a  most  felicitous 
harmony  with  the  inspiration  that  dwells  within. 
Take  it  all  in  all,  it  is  a  book  we  have  often  dreamed 
Of,  but  dreamed  not  that  it  would  ever  meet  our 
waking  eye  as  a  tangible  reality. — Nashville  Journal 
of  Medicine. 

We  deem  it  fortunate  that  the  splendid  work  of 
Dr.  La  Roche  should  have  been  issued  from  the  press 
at  this  particular  time.  The  want  Of  a  reliable  di- 
gest of  all  that  is  known  in  relation  in  this  frightful 
malady  has  long  been  felt — a  Want  very  satisfactorily 
met  in  the  work  before  us.  We  deem  it  but  faint 
praise  to  say  that  Dr.  La  R<che  has  succeeded  in 
presenting  the  profession  with  an  able  and  complete 
monograph,  one  which  will  find  its  way  into  every 
well  ordered  library. —  Va.  Stethoscope. 


BY  THE  SAME  AUTHOR. 

PNEUMONIA ;  its  Supposed  Connection,  Pathological  and  Etiological,  with  Au- 
tumnal Fevers,  including  an  Inquiry  into  the  Existence  and  Morbid  Agency  of  Malaria.  In  one 
handsome  octavo  volume,  extra  cloth,  of  500  pages.    $3  00. 

MILLER  (HENRY),  M.  D., 

Professor  of  Obstetrics  and  Diseases  of  Women  and  Children  in  the  University  of  Louisville. 

PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS,  &c.j  including  the  Treat- 

ment  of  Chronic  Inflammation  of  the  Cervix  and  Body  of  the  Uterus  considered  as  a  frequent 
cause  of  Abortion.  With  about  one  hundred  illustrations  on  wood.  In  one  very  handsome  oc- 
tavo volume,  of  over  GOO  pages.     {Now  Ready.)     $3  75. 

The  reputation  of  Dr.  Miller  as  an  obstetrician  is  too  widely  spread  to  require  the  attention  of 
the  profession  to  be  specially  called  to  a  volume  containing  the  experience  of  his  long  and  extensive 
practice.  The  very  favorable  reception  accorded  to  his  "  Treatise  on  Human  Parturition,"  issued 
some  years  since,  is  an  earnest  that  the  present  work  will  fulfil  the  author's  intention  of  providing 
within  a  moderate  compass  a  complete  and  trustworthy  text-book  for  the  student,  and  book  of  re- 
ference for  the  practitioner.  Based  to  a  certain  extent  upon  the  formerwork,  but  enlarged  to  more 
than  double  its  size,  and  almost  wholly  rewritten,  it  presents,  besides  the  matured  experience  of 
the  author,  the  most  recent  views  and  investigations  of  modern  obstetric  writers,  such  as  Dt;bois, 
Cazeadx,  Simpson,  Tyler  Smith,  &c,  thus  embodying  the  results  not  only  of  the  .American, 
but  also  of  the  Paris,  the  London,  and  the  Edinburgh  obstetric  schools.  The  author's  position  for  sr> 
many  years  as  a  teacher  of  his  favorite  branch,  has  given  him  a  familiarity  with  the  wants  of  stu- 
dents and  a  facility  of  conveying  instruction,  which  cannot  fail  to  render  the  volume  eminently 
adapted  to  its  purposes. 


We  congratulate  the  author  that  the  task  is  done. 
We  congratulate  him  that  he  has  given  to  the  medi- 
cal public  a  work  which  will  secure  for  him  a  high 
and  permanent  position  among  the  standard  autho- 
rities on  the  principles  and  practice  of  obstetrics. 
Congratulations  are  not  less  due  to  the  medical  pro- 
fession of  this  country,  on  the  acquisition  of  a  trea- 
tise embodying  the  results  of  the  studies,  reflections, 
and  experience  of  Prof.  .Miller.  Few  men,  if  any. 
in  this  country,  are  more  competent  than  he  to  write 
on  this  department  of  medicine.  Engaged  for  thirty- 
five  years  in  an  extended  practice  of  obstetrics,  for 
many  years  a  teacher  of  this  branch  of  instruction 
in  one  of  the  largest  of  our  institutions,  a  diligent 
student  as  well  asa  careful  observer,  an  original  and 
independent  thinker,  wedded  to  no  hobbies,  ever 
ready  to  Consider  without  prejudice  new  views,  and 
to  adopt  innovations  if  they  are  really  improvements, 
and  withal  a  clear,  agreeable  writer,  a  practical 
treatise  from  his  pen  could  not  fail  to  possess  great 
value.  Returning  to  Prof.  Miller's  work  we  have 
only  to  add  that  we  hope  most  sincerely  it  will  be  in 
the  hands  of  every  reading  and  thinking  practitioner 
of  this  country.— Buffalo  Med  Journal,  Mar.  J853. 


In  fact,  this  volume  must  take  its  place  among  the 
standard  systematic  treatises  on  obstetrics;  a  posi- 
tion to  which  its  merits  justly  entitle  it.  The  style 
is  such  that  the  descriptions  are  clear,  and  each  sub- 
ject is  discussed  and  elucidated  with  due  regard  to 
Us  practical  bearings,  which  cannot  fail  to  make  it 
acceptable  and  valuable  to  both  students  and  prac- 
titioners. We  cannot,  however,  close  this  brief 
notice  without  congratulating  the  author  and  the 
profession  on  the  production  of  such  an  excellent 
treatise.  The  author  is  a  western  man  of  whom  we 
feel  proud,  and  we  cannot  but,  think  that  his  book 
will  find  many  readers  and  -warm  admirers  wherever 
obstetrics  is  taught  and  studied  as  a  science  and  an 
art. — The  Cincinnati  Lancetand  Observer,  Feb.  1858. 

A  most  respeclahle  and  valuable  addition  to  our 
home  medical  literature,  and  one  reflecting  credit 
alike  on  the  author  and  the  institution  to  which  he 
is  attached.  The  student  will  find  in  this  work  a 
most  useful  guide  to  his  studies;  the  country  prac- 
titioner, rusty  in  his  reading,  can  obtain  from  its 
pages  a  fair  resume  of  the  modern  literature  of  the 
science;  and  we  hope  to  see  this  American  produc- 
tion generally  consulted  by  the  profession. —  Va. 
Med.  Journal,  Feb.  1858. 


AND    SCIENTIFIC    PUBLICATIONS. 


21 


MEIGS  (CHARLES   D.),  M.  D., 

Professor  of  Obstetrics,  &c.  in  the  Jefferson  Medical  College,  Philadelphia. 

OBSTETRICS :   THE   SCIENCE   AND  THE  -ART.     Third  edition,  revised 

and  improved.    With  one  hundred  and  twenty-nine  illustrations.  In  one  beautifully  printed  octavo 

volume,  leather,  of  seven  hundred  and  fifty-two  large  pages.     $3  75. 

The  rapid  demand  for  another  edition  of  this  work- is  a  sufficienl  expression  of  the  favorable 
verdict  of  the  profession.  In  thus  preparing  it  a  third  time  for  the  press,  the  author  has  endeavored 
to  render  it  in  every  respect  worthy  of  the  favor  which  it  has  received.  To  accomplish  this  he 
has  thoroughly  revised  it  in  every  part.  Some  portions  have  been  rewritten,  others  added,  new 
illustrations  have  been  in  many  instances  substituted  for  such  as  w.-rc  oot  deemed  satisfactory, 
while,  by  an  alteration  in  the  typographical  arrangement,  the  size  of  the  work  has  qoI  been  increased, 
and  the  price  remains  unaltered.  In  itspresent  improved  form,  it  is,  therefore,  hoped  that  the  work 
will  continue  to  meet  the  wants  of  the  American  profession  as  a  sound,  practical,  and  extended 
System  of  Midwifery. 


Though  the  work  has  received  only  five  pages  of 
enlargement,  its  chapters  throughout  wear  the  im- 
pressof  careful  revision.  Expunging  and  rewriting, 
remodelling  its  sentences,  with  occasional  new  ma- 
terial, all  evince  a  lively  desire  that  it  shall  deserve 
to  be  regarded  as  improved  in  manner  as  well  as 
matter.  In  the  matter,  every  stroke  of  the  pen  has 
increased  the  value  of  the  book,  both  in  expungings 
and  additions  — Western  Lancet,  Jan.  1S57. 


The  best  American  work  on  Midwiferv  that  is 
accessible  to  the  student  and  practitioner— iV.  W. 
Mtd.  an,/  Surg.  Journal,  Jan.  1-57. 

This  is  a  standard  work  by  a  great  American  Ob- 
stetrician. It  is  the  third  and  las'  edition,  and,  in 
the  lai  guage  of  the  preface,  the  author  lias  "brought 
the  subject  up  to  the  latest  dates  of  real  improve- 
ment in  our  art  au.l  Science." — Nashville  Journ.  of 
Med.  and  Surg.,  May,  lb57. 


BY  THE  SAME   AUTHOR.      (Lately  Issued.) 

HER  DISEASES  AND  THEIR  REMEDIES.     A  Series  of  Lec- 

Class.     Third  and  Improved  edition.    In  one  large  and  beautifully  printed  octavo 


WOMAN : 

tures  to  hi 

volume,  leather.        pp.  672.     $3  60 

The  gratifying  appreciation  of  his  labors,  as  evinced  by  the  exhaustion  of  two  large  impressions 
of  this  work  within  a  few  years,  has  not  been  lost  upon  the  author,  who  has  endeavored  in  every 
way  to  render  it  worthy  of  the  favor  with  which  it  has  been  received.  The  opportunity  thus 
afforded  for  a  second  revision  has  been  improved,  and  the  work  is  now  presented  as  in  every  way 
superior  to  its  predecessors,  additions  and  alterations  having  been  made  whenever  the  advance  of 
science  has  rendered  them  desirable.  The  typographical  execution  of  the  work  will  also  be  found 
to  have  undergone  a  similar  improvement,  and  the  work  is  now  confidently  presented  as  in  every 
way  worthy  the  position  it  has  acquired  as  the  standard  American  text-book  on  the  Diseases  of 
Females. 


It  contains  a  vast  amount  of  practical  knowledge, 
by  one  who  has  accurately  observed  and  retained 
the  experience  of  many  years,  and  who  tells  the  re- 
sult in  a  free,  familiar,  and  pleasant  manner. — Dub- 
lin Quarterly  Journal. 

There  is  an  off-hand  fervor,  a  glow,  and  a  warm- 
heartedness infecting  the  eff>rt  of  Dr.  Meigs,  which 
is  entirely  captivating,  and  which  absolutely  hur- 
ries the  reader  through  from  beginning  to  end.  Be- 
sides, the  book  teems  with  solid  instruction,  and 
it  shows  the  very  highest  evidence  of  ability,  viz., 
the  clearness  with  which  the  information  is  pre- 
sented. We  know  of  no  better  test  of  one's  under- 
standing a  subject  than  the  evidence  of  the  power 
of  lucidly  explaining  it.  The  most  elementary,  as 
well  as  the  obscurest  subjects,  under  the  pencil  of 
Prof.  Meigs,  are  isolated  and  made  to  stand  out  in  | 

by  the  same  author.     (Lately  Published.') 

ON    THE    NATURE,    SIGNS,    AND    TREATMENT    OF    CHILDBED 

FEVER.     In   a  Series  of  Letters  addressed  to  the  Students  of  his  Class.     In  one  handsome 
octavo  volume,  extra  cloth,  of  365  pages.     §2  50. 


such  bold  relief,  as  to  produce  distinct  impressions 
upon  the  mind  and  memory  of  the  reader.  —  The 
Charleston  Med.  Journal. 

Professor  Meigs  has  enlarged  and  amended  this 
great  work,  for  such  it  unquestionably  is,  having 
passed  the  ordeal  of  criticism  at  home  and  abroad, 
but  been  improved  thereby  ;  for  in  this  new  edition 
the  author  has  introduced  real  improvements,  and 
increased  the  value  and  utility  of  the  book  im- 
measurably. It  presents  so  many  novel,  bright, 
and  sparkling  thoughts;  such  an  exuberance  of  new 
ideas  on  almost  every  page,  that  we  confess  our- 
selves to  have  become  enamored  with  the  book 
and  its  author  ;  and  cannot  withhold  on r  congratu- 
lations from  our  Philadelphia  confreres,  that  such  a 
teacher  is  in  their  service. — N.  Y.  Med.  Gazette. 


The  instructive  and  interesting  author  of  this 
work,  whose  previous  labors  in  the  department  of 
medicine  which  he  so  sedulously  cultivates,  have 
placed  his  countrymen  under  deep  and  abiding  obli- 
gations, again  challenges  their  admiration  in  the 
fresh  and  vigorous,  attractive  and  racy  pages  before 
ns.  It  is  a  delectable  book.  #  *  #  This  treatise 
upon  child-bed  fevers  will  have  an  extensive  sale, 
being  destined,  as  it  deserves,  to  find  a  place  in  the 
library  of  every  practitioner  who  scorns  to  lag  in  the 
rear  .—Nashville  Journal  of  Medi:ine  and  Surgery. 


I 


This  book  will  add  more  to  his  fame  than  either 
of  those  which  bear  his  name.  Indeed  we  doubt 
whether  any  material  improvement  will  be  made  on 
the  teachings  of  this  volume  for  a  century  to  come, 
since  it  is  so  eminently  practical,  and  based  on  pro- 
found knowledge  of  the  sri'nce  and  consummate 
skill  in  the  art  of  healing,  and  ratified  by  an  ample 
and  extensive  experience,  such  ns  few  men  have  the 
industry  or  good  fortune  to  acquire. — N.  Y.  Med. 
Gazette. 


BY    THE   SAME   AUTHOR:    WITH  COLORED  PLATES. 


A  TREATISE  ON  ACUTE  AND  CHRONIC  DISEASES  OF  THE  NECK 

OF  THE  UTERUS.     With  numerous  plates,  drawn  and  colored  from  nature  in  the  highest 
style  of  art.     In  one  handsome  octavo  volume,  extra  cloth.     $4  50. 


MAYXB'S    DISPENSATORY     AXD     THERA-    MALGAIGNE'S  OPERATIVE  SURGERY,  based 


PEUTICAL  REMEMBRANCER.  Comprising 
the  entire  lists  of  Materia  Medica,  with  every 
Practical  Formula  contained  in  the  three  British 
Pharmacopoeias.  Edited,  with  the  addition  of  the 
Formulae  of  the  U.  S.  Pharmacopoeia,  by  R.  E. 
Griffith,  M.D.   1  l2mo.  vol.  ex.  cl., 300  pp.  75  c. 


on  .Normal  and  Pathological  Anatomy.  Trans- 
lated from  the  French  iiy  FREDERICK  BrittaN, 
A.  B.,M.  D..  With  numerous  illustrations  on  wood. 
In  one  handsome  octavo  volume,  extra  cloth,  of 
nearly  six  hundred  pages.    $2  25. 


23 


BLANCHARU    &    LEA'S    MEDICAL 


MACLISE    (JOSEPH),    SURGEON. 
SURGICAL  ANATOMY.     Forming  one  volume,   very  large  imperial  quarto. 

Willi  M\iy-i'iirlii  large  and  splendid  Plates,  drawn  in  the  best  style  and  beautifully  colored.  Con- 
taining one  hundred  and  ninety  Figures,  many  of  them  the  size  of  life.  Together  with  copious 
and  explanatory  letter-press.  Strongly  and  handsomely  hound  in  extra  cloth,  being  one  of  the 
cheapesl  and  best  executed  Surgical  works  as  yet  issued  in  this  country.    $11  00. 

*„*   The  size  of  this  work  prevents  ils  transmission  through  the  post-office  as  a  whole,  hut  those 
who  desire  to  havi  forwarded  by  mail,  can  receive  them  in  five  parts,  done  up  in  stout 

wrappers.     Price  $9  00. 

One  of  the  greatest  artistic   triumphs  of  the  age  i  of  keeping  up  hiB  anatomical  knowledge. — Medical 
in  Burgical  Anatomy. — Briti^li  Anurieem  Medical    Times. 

The  mechanical  execution  cannot  be  excelled. — 


Too  much  cannot  be  said  in  its'praise;  indeed, 
We  have  not  language  to  do  it  justice. — Ohio  Medi- 
cal and  Surgical  Journal. 

The  most  admirable  surgical  atlas  we  have  seen. 
To  the  practitioner  deprived  or  demonstrative  dis- 
sections iipcin  the  human  subject,  it  is  an  invaluable 
companion. — N.  J.  Mtdical  Reporter. 

The  most  accurately  engraved  and  beautifully 
colored  plates  we  have  ever  seen  in  an  American 
hook — one  of  the  best  and  cheapest  surgical  works 
ever  published. — Buffalo  Medical  Journal. 

It  is  very  rare  that  so  elegantly  printed,  go  well 
illustrated,  and  so  useful  a  work,  is  offered  at  so 
moderate  a  price. — Charleston  Medical  Journal. 

Its  plates  can  boast,  a  superiority  which  places 
them  almost  beyond  the  reach  of  competition. — Medi- 
cal Examiner. 

Every  practitioner,  we  think,  should  have  a  work 
of  this  kind  within  reach. — Southern.  Medical  and 
Surgical  Journal. 

No  such  lithographic  illustrations  of  surgical  re- 
gions have  hitherto,  we  think,  been  given. — Boston 
Medical  and  Surgical  Journal. 

As  a  surgical  anatomist,  Mr.  Maclise  has  proba- 
bly no  superior. — British  and  Foreign  Medico-Chi- 
rurgical  Review. 

Of  great  value  to  the  student  engaged  in  dissect- 


Transylvania  Mtdical  Journal. 

A  work  which  has  no  parallel  in  point  of  accu- 
racy and  cheapness  in  the  English  language. — JV.  Y. 
Journal  of  Medicine. 

To  all  engaged  in  the  Btudy  or  practice  of  their 
profession,  bucIi  a  work  is  almost  indispensable. — 
Dublin  Quarterly  Medical  Journal. 

No  practitioner  whose  means  will  admit  should 
fail  to  possess  it. — Ranking's  Abstract. 

Country  practitioners  will  find  these  plates  of  im- 
mense value. — N.  Y.  Medical  Gazette. 

We  are  extremely  gratified  to  announce  to  the 
profession  the  completion  of  this  truly  magnificent 
work,  which,  as  a  whole,  certainly  stands  unri- 
valled, both  for  accuracy  of  drawing,  beauty  of 
coloring,  and  all  the  requisite  explanations  of  the 
subject  in  hand. — The  New  Orleans  Medical  and 
Surgical  Journal. 

This  is  by  far  the  ablest  work  on  Surgical  Ana- 
tomy that  has  come  under  our  observation.  We 
know  of  no  other  work  that  would  justify  a  stu- 
dent, in  any  degree,  for  neglect  of  actual  dissec- 
tion. Jn  those  sudden  emergencies  that  so  often 
arise,  and  which  require  the  instantaneous  command 
of  minute  anatomical  knowledge,  a  work  of  this  kind 
keeps  the  details  of  the  dissecting-room  perpetually 
fresh  in  the  memory. — The  Western  Journal  of  Medi- 


ing,  and  to  the  surgeon  at  a  distance  from  the  means  I  cine  and  Surgery 

BSsT"  The  very  low  price  at  which  this  work  is  furnished,  and  the  beauty  of  its  execution, 
require  an  extended  sale  to  compensate  the  publishers  for  the  heavy  expenses  incurred. 

MULLER'S  PRINCIPLES  OF^PHYSICS  AND  METEOROLOGY.    Edited, 

with  Additions,  by  R.  Eglesfeld  Griffith,  M.  D.     In  one  large  and  handsome  octavo  volume, 
extra  cloth,  with  550  wood-cuts,  and  two  colored  plates,    pp.  636.     $3  50. 


MOHR  (FRANCIS),  PH.  D.,  AND  REDWOOD  (TH  EOPH  I  LUS). 
PRACTICAL    PHARMACY.     Comprising  the  Arrangements,  Apparatus,  and 

Manipulations  of  the  Pharmaceutical  Shop  and  Laboratory.  Edited,  with  extensive  Additions, 
by  Prof.  William  Procter,  of  the  Philadelphia  College  of  Pharmacy.  In  one  handsomely 
printed  octavo  volume,  extra  cloth,  of  570  pages,  with  over  500  engravings  ou  wood.     $2  75. 


MACKENZIE   (W.),    M .  D., 

Surgeon  Oculist  in  Scotland  in  ordinary  to  Her  Majesty,  &c.&c. 

A  PRACTICAL   TREATISE  ON   DISEASES   AND  INJURIES  OF   THE 

EVE.  To  which  is  prefixed  an  Anatomical  Introduction  explanatory  of  a  Horizontal  Section  of 
the  Human  Eyeball,  by  Thomas  Wharton  Jones,  F.  R.  S.  From  the  Fourth  Revised  and  En- 
larged London  Edition.  With  Notes  and  Additions  by  Addinell  Hewson,  M.  D.,  Surgeon  to 
Wills  Hospital,  &c.  &c.  In  one  very  large  and  handsome  octavo  volume,  leather,  raised  bands,  with 
plates  and  numerous  wood-cuts.     $5  25. 


The  treatise  of  Dr.  Mackenzie  indisputably  holds 
the  first  place,  and  forms,  in  respect  of  learning  and 
research,  an  Encyclopaedia  unequalled  in  extent  by 
any  other  work  of  the  kind,  either  English  or  foreign. 
— Dixon  on  Diseases  of  the  Eye. 

Few  modern  books  on  any  department  of  medicine 
or  surgery  have'met  with  such  extended  circulation, 
or  have  procured  for  their  authors  a  like  amount  of 
European  celebrity.     The  immense  research  which  i 
it  displayed,  the  thorough   acquaintance  with   the  I 
subject,  practically  as  well  as  theoretically,  and  the  ! 
able  manner  in  which  the  author's  stores  of  learning 
and  experience  Were  rendered  availablefor  general 
use,  at  onrc  procured  for  the  first  edition,  as  well  on 
the  continent  as  in  this  country,  that  "high  position 
as  a  standard  work  which  each  successive  edition 
has  more  firmly  established,  in  spite  of  the  attrac- 
tions of  several  rivals  of  no  mean  ability.    We  con- 


sider it  the  duty  of  every  one  who  has  the  love  of  his 
profession  and  the  welfare  of  his  patient  at  heart,  to 
make  himself  familiar  with  this  the  most  complete 
work  in  the  English  language,  upon  the  diseases  of 
the  eye. — Med.  Times  and  Gazette. 

The  fourth  edition  of  this  standard  work  will  no 
doubt  be  as  fully  appreciated  as  the  three  former  edi- 
tions. It  is  unnecessary  to  say  aword  in  its  praise, 
for  the  verdict  has  already  been  passed  upon  it  by 
the  most  competent  judges,  and  "  Mackenzie  on  the 
Eye"  has  justly  obtained  a  reputation  which  it  is 
no  figure  of  speech  to  call  world-wide. — British  and 
Foreign  Medico-C hirurgical  Review. 

This  new  edition  of  Dr.  Mackenzie's  celebrated 
treatise  on  diseases  of  the  eye,  is  truly  a  miracle  of 
industry  and  learning.  We  need  scarcely  say  that 
he  has  entirely  exhausted  the  subject  of  his  specialty. 
— Dublin  Quarterly  Journal. 


AND    SCIENTIFIC    PUBLICATIONS. 


23 


MILLER  (JAMES),   F.  R.  S.  E., 

Professor  of  Surgery  in  the  University  of  Edinburgh,  &c. 

PRINCIPLES  OF  SURGERY.     Fourth  American,  from  the  third  and  revised 

Edinburgh  edition.    In  one  large  and  very  beautiful  volume,  leather,  of  700  pages,  with  two 

hundred  and  forty  exquisite  illustrations  on  wood.     (Jtt.it  Issued,  1856.)        $3  75. 

The  extended  reputation  enjoyed  by  this  work  will  be  fully  maintained  by  the  present  edition. 
Thoroughly  revised  by  the  author,  it  will  be  found  a  clear  and  compendious  exposition  of  surgical 
science  in  its  most  advanced  condition. 

In  connection  with  the  recently  issued  third  edition  of  the  author's  "  Practice  of  Surgery,"  it 
forms  a  very  complete  system  of  Surgery  in  all  its  branches. 


The  work  of  Mr.  Miller  is  too  well  and  too  favor- 
ably known  among  us,  as  one  of  our  best  text-books, 
to  render  any  further  notice  of  it  necessary  than  the 
announcement  of  a  new  edition,  the  fourth  in  our 
country,  a  proof  of  its  extensive  circulation  among 
us.  As  a  concise  and  reliable  exposition  of  the  sci- 
ence of  modern  surgery,  it  stands  deservedly  high — 
we  know  not  its  superior. — Boston  Med.  and  Surg. 
Journal. 

It  presents  the  most  satisfactory  exposition  of  the 
modern  doctrines  of  the  principles  of  surgery  to  be 
found  in  any  volume  in  any  language. — N.  Y.  journal 
of  Medicine. 

The  work  takes  rank  with  Watson's  Practice  of 
Physic;  it  certainly  does  not  fall  behind  that  great 
work  in  soundness  of  principle  or  depth  of  reason- 
ing and  research.    No  physician  who  values  his  re-  | 

BY  the  same  author.     (Now  Ready.) 

THE    PRACTICE   OF   SURGERY.      Fourth  American  from  the  last  Edin- 

burgh  edition.     Pievised  by  the  American  editor.     Illustrated  by  three  hundred  and  sixty-four 
engravings  on  wood.     In  one  large  octavo  volume,  leather,  of  nearly  700  pages.     $3  75. 

No  encomium  of  ours  could  add  to  the  popularity  [  his  works,  both  on  the  principles  and  practice  of 
of  Miller's  Surgery.  Its  reputation  in  this  country  |  surgery  have  been  assigned  the  highest  rank.  If  we 
is  unsurpassed  by  that  of  any  other  work,  and,  when  were  limited  to  but  one  work  on  surgery,  that  one 
taken  in  connection  with  the  author's  Principles  of1  should  be  Miller's,  as  we  regard  itas superior  to  all 


putation,  or  seeksthe  interests  of  his  clii-nts.  can 
acquit  himself  before  his  God  and  the  world  without 
making  himself  familiar  with  the  sound  and  philo- 
sophical views  developed  in  the  foregoing  book. — 
New  Orleans  Med.  and  Surg.  Journal. 

Without  doubt  the  ablest  exposition  of  the  prin- 
ciples of  that  branch  of  the  healing  art  in  any  lan- 
guage. This  opinion,  deliberately  formed  after  a 
careful  study  of  the  first  edition,  we  have  had  no 
cause  to  change  on  examining  the  second.  This 
edition  has  undergone  thorough  revision  by  the  au- 
thor; many  expressions  have  been  modified,  and  a 
mass  of  new  matter  introduced.  The  book  is  got  up 
in  the  finest  style,  and  is  an  evidence  of  the  progress 
of  typography  in  our  country. — Charleston  Medical 
Journal  and  Review. 


Surgery,  constitutes  a  whole,  without  reference  to 
which  no  conscientious  surgeon  would  be  willing 
to  practice  his  art.  The  additions,  by  Dr.  Sargent, 
have  materially  enhanced  the  value  of  the  work. — 
Southern  Medical  and  Surgical  Journal. 

It  is  seldom  that  two  volumes  have  ever  made  so 
profound  an  impression  in  so  short  a  time  as  the 
"  Principles"  and  the  "  Practice"  of  Surgery  by 
Mr.  Miller — or  so  richly  merited  the  reputation  they 
have  acquired.  The  author  is  an  eminently  sensi- 
ble, practical,  and  well-informed  man,  who  knows 
exactly  what  he  is  talking  about  and  exactly  how  to 
talk  it. — Kentucky  Medical  Recorder. 

By  the  almost  unanimous  voice  of  the  profession, 


others. — St.  Louis  Med.  and  Surg.  Journal. 

The  author,  distinguished  alike  as  a  practitioner 
and  writer,  has  in  tins  and  his  "  Principles,"  pre- 
sented to  the  profession  one  of  the  most  complete  and 
reliable,  systems  of  Surgery  extant.  His  style  of 
writing  is  original,  impressive,  and  engaging,  ener- 
getic, concise,  and  lucid.  Few  have  the  faculty  of 
condensing  so  much  in  small  space,  and  at  the  same 
time  so  persistently  holding  the  attention;  indeed, 
he  appears  to  make  the  very  process  of  condensation 
a  means  of  eliminating  attractions.  Whether  as  a 
text-book  for  students  or  a  book  of  reference  for 
practitioners,  it  cannot  be  too  strongly  recommend- 
ed.— Southern  Journal  of  Med.  and  Phys.  Sciences. 


MONTGOMERY  (W.  F.),    M, 


D.,   M 


R.  I.  A.,  &.c. 


Professor  of  Midwifery  in  the  King  and  Queen's  College  of  Physicians  in  Ireland,  &c. 

AN  EXPOSITION  OF  THE  SIGNS  AND  SYMPTOMS  OF  PREGNANCY. 

With  some  other  Papers  on  Subjects  connected  with  Midwifery.     From  the  second  and  enlarged 
English  edition.    With  two  exquisite  colored  plates,  and  numerous  wood-cuts.     In  one  very 
handsome  octavo  volume,  extra  cloth,  of  nearly  600  pages.     (Just  Issued,  1857.)     $3  75. 
The  present  edition  of  this  classical  volume  is  fairly  entitled  to  be  regarded  as  anew  work,  every 
sentence  having  been  carefully  rewritten,  and  the  whole  increased  to  more  than  double  the  original 
size.     The  title  of  the  work  scarcely  does  justice  to  the  extent  and  importance  of  the  topics 
brought  under  consideration,  embracing,  with  the  exception  of  the  operative  procedures  of  mid- 
wifery, almost  everything  connected  with  obstetries,  either  directly  or  incidentally  ;  and  there  are 
few  physicians  who'will  not  find  in  its  pages  much  that  will  prove  of  great  interest  and  value  in 
their  dailv  practice.     The  special  Essays  on  the  Period  of  Human  Gestation,  the  Si^ns  of  Delivery, 
and  the  Spontaneous  Amputation  and  other  Lesions  oftheFuetus  in  Utero  present  topics  of  the 
highest  interest  fully  treated  and  beautifully  illustrated. 

In  every  point  of  mechanical  execution  the  work  will  be  found  one  of  the  handsomest  yet  issued 
from  the  American  press. 


A  book  unusually  rich  in  practical  suggestions. — 
Am.  Journal  Med.  Sciences,  Jan.  1S57. 

These  several  subjects  so  interesting  in  them- 
selves, and  so  important,  every  one  of  them,  to  the 
most  delicate  and  precious  of  social  relations,  con- 
trolling often  the  honor  and  domestic  peace  of  a 
family,  the  legitimacy  of  offspring,  or  the  life  of  its 
parent,  are  all  treated  with  an  elegance  of  diction, 
fulness  of  illustrations,  acutenessand  justice  of  rea- 
soning, unparalleled  in  obstetrics,  and  unsurpassed  in 
medicine.  The  reader's  interest  can  never  flag,  so 
fresh,  and  vigorous,  and  classical  is  our  author's 
style;  and  one  forgets,  in  the  renewed  charm  of 
every  page,  that  it,  and  every  line,  and  every  word 


has  been  weighed  and  reweighed  through  years  of 
preparation;  that  this  is  of  all  others  the  book  of 
Obstetric  Law,  on  each  of  its  several  topics  ;  on  all 
points  connected  with  pregnancy,  to  be  everywhere 
received  as  a  manual  of  special  jurisprudence,  at 
once  announcing  fact,  affording' argument,  establish- 
ing precedent,  and  governing  alike  the  juryman,  ad- 
vocate, and  judge.  It  is  not  merely  in  its  legal  re- 
lations that  we  lind  this  work  so  interesting.  Hardly 
a  page  but  that  has  its  hints  or  facts  important  to 
the  general  practitioner  ;  and  not  a  chapter  without 
especial  matter  for  the  anatomist,  physiologist,  Or 
pathologist.— A'.  A.  Med.-Chir.  Review,  .March, 
1857. 


BLANCHARD    &    LEA'S    MEDICAL 


NEILL  (JOHN),   M.  D., 
Surgeon  to  the  Pennsylvania  Hospital,  &c;  and 

FRANCIS  GURNEY   SMITH,   M.  D., 

Professor  of  Institutes  of  Medicine  in  the  Pennsylvania  Medical  College. 

AN  ANALYTICAL  COMPENDIUM  OF  THE  VARIOUS  BRANCHES 

OF  MEDICAL  SCIENCE;  for  the  Use  and  Examination  of  Students.     A  new  edition,  revised 
and  improved.     In  one  very  large  and  handsomely  printed  royal  12mo.  volume,  of  about  one 
thousand  pages,  with  374  wood-cuts.     Strongly  bound  in  leather,  with  raised  bands.     $3  00. 
The  very  flattering  reception  which  has  been  accorded  to  this  work,  and  the  high  estimale  placed 
upon  it  by  the  profession,  as  evinced  by  the  constant  and  increasing  demand  which  has  rapidly  ex- 
hausted two  large  editions,  have  stimulated  the  authors  to  render  the  volume  in  its  present  revision 
more  worthy  of  the  success  which  has  attended  it.     It  has  accordingly  been  thoroughly  examined, 
and  such  errors  as  had  on  former  occasions  escaped  observation  have  been  corrected,  and  whatever 
additio  i-  were  necessary  to  maintain  it  on  a  level  with  the  advance  of  science  have  been  introduced. 
The  e  Ltended  series  of  illustrations  has  been  still  further  increased  and  much  improved,  while,  by 
a  slighl  enlargement  of  the  page,  these  various  additions  have  been  incorporated  without  increasing 
the  bulk  of  the  volume. 

The  work-  is,  therefore,  again  presented  as  eminently  worthy  of  the  favor  with  which  it  has  hitherto 
been  received.  As  a  book  for  daily  reference  by  the  student  requiring  a  guide  to  his  more  elaborate 
text-books,  as  a  manual  for  preceptors  desiring  to  stimulate  their  students  by  frequent  and  accurate 

examinai  i< r  as  a  source  from  which  the  practitioners  of  older  date  may  easily  and  cheaply  acquire 

a  knowledge  of  the  changes  and  improvement  in  professional  science,  its  reputation  is  permanently 
established. 

The  best  work  of  the  kind  with  which  we  are  I  the  students  is  heavy,  and  review  necessary  for  an 
acquainted.— Med.  Examiner.  '  examination,  a  compend  is  not  only  valuable,  but 

who  examine  their  pupils.     It  will  save  the  teacher     Pavements  and  discoveries  are  exnlcitly     though 
much  labor  by  enabling  him  readily  to  recall  all  of  i  concisely,  laid  before  the  student.     There  is  a  class 

the   points    upon  wh.ci,   his    pupils'  should   be  ex-  towh^?r^^CTflS»S 

amined.     A  work  of  this  sort  should  be  in  the  hands  as  worth  its  weight  in  silver-that  class  is  the gradu- 

of  every  one  who  takes  pupils  into  his  office  with  a  *tes  in  medicine  of  more  than  ten  years    standing 
view  Of  examining  them     and  this  is  unquestionably  ,  who  have  not  studied  medicine  since      They  will 

the  best  Of  its  dais-Transylvania  Med.  Journal.  perhaps  find  out  from  it  that  the  scenee  ,snot  exactly 

,  now  what  it  was  when  they  left  it  oiT. — Ine  btet/io- 

In  the  rapid  course  of  lectures,  where  work  for  scope 


NEILL   (JOHN),    M.  D., 

Professor  of  Surgery  in  the  Pennsylvania  Medical  College,  &c. 

OUTLINES  OF  THE  VEINS  AND  LYMPHATICS.     With  handsome  colored 

plates.     1  vol.,  cloth.  SI  25. 

OUTLINES  OF  THE  NERVES.     With  handsome  plates.     1  vol.,  cloth.  $1  25. 


NELIGAN  (J.    MOORE),  M.  D.,  M.  R.  I.  A.,  &c. 

(A  splendid  ivork.     Just  Issued.) 

ATLAS  OF  CUTANEOUS  DISEASES.     In  one  beautiful  quarto  volume,  extra 

cloth,  with  splendid  colored  plates,  presenting  nearly  one  hundred  elaborate  representations  of 

disease.     $4  50. 

This  beautiful  volume  is  intended  as  a  complete  and  accurate  representation  of  all  the  varieties 
of  Diseases  of  the  Skin.  While  it  can  be  consulted  iu  conjunction  with  any  work  on  Practice,  it  has 
especial  reference  to  the  author's  "  Treatise  on  Diseases  of  the  Skin,"  so  favorably  received  by  the 
profession  some  years  since.  The  publishers  feel  justified  in  saying  that  few  more  beautifully  exe- 
cuted plates  have  ever  been  presented  to  the  profession  of  this  country. 

A  compend  which  will  very  much  aid  the  praeti-  long  existent  desideratum  much  felt  by  the  largest 
tioner  in  this  difficult  branch  of  diagnosis.  Taken  class  of  our  profession.  It  presents,  in  quarto  size, 
with  the  beautiful  plates  of  the  Atlas,  which  are  16  plates,  each  containing-  from  3  to  6  figures,  and 
remarkable  for  their  accuracy  and  beauty  of  color-  forming  in  all  a  total  of  90  distinct  representations 
ing.  it  constitutes  a  very  valuable  addition  to  the  of  the  different  species  of  skin  affections,  grouped 
library  of  a  practical  man.—  Buffalo  Med.  Journal,  together  in  genera  or  families.  The  illustrations 
Sept   1856  have  been  taken  from  nature,  and   have  I  een  copied 

Nothing  is  often  more  difficult  than  the  diagnosis  withsuch  fidelity  that  they  present  a  striking  picture 
of  disease  of  the  skin  ;  and  hitherto,  the  only  works  «f  "fe  j  »  which  the  reduced  scale  up  y  s< yes  to 
containing  illustrations  have  been  at  rather  incon-  S've,  at  a coup  dad, the  remarkale  peculiarities 
venient  prices-prices,  indeed,  that  prevented  gene-  "f  <*?h  individual  variety.  And  while  thus  the  dis- 
ral  us.-.'  The  work  before  us  will  supply  a  want  ™se  ls  rendered  more  definable,  there  ,s  jet  no  loss 
lomrfelt,  and  minister  to  a  more  perfect  acquaintance  £  proportion  incurred  by  the  necessar  eoncentra- 
With  the  nature  and  treatment  of  a  very  frequent  '"»;.  Each  figure  ^highly  colored  and  so  truthful 
and  troublesome  form  of  disease.-0/.to  Med and  ha8,the  *nis\  been  that  the  mos t  fas  l.d.u "observer 
<.-./r.r    ;  „-„„;    r.,i,.    iqsp.  ,  could  not  justly  take  exception  to  the  correctness  of 

burg.  Journal,  Julj  ,  1856.  the  executinn  'o[  the  pictures  unuur  bis  scrutiny— 

Neligan's  Atlas  of  Cutaneous  Diseases  supplies  a    Montreal  Med.  Chronicle. 

BY  THE  SAME  AUTHOR. 

A   PRACTICAL  TREATISE    ON   DISEASES   OF  THE    SKIN.     Second 

American  edition.     In  one  neat  royal  12mo.  volume,  extra  cloth,  of  334  pages.     $1  00. 

££^*  The  two  volumes  will  be  sent  by  mail  on  receipt  of  Five  Dollars. 

OWEN    ON    THE    DIFFERENT    FORMS    OF  I      One  vol.  royal  12mo.,  extra  cloth,  with  numerous 
THE   SKELETON,   AND    OF    THE    TEETH.  |      illustrations.     (Just  Issued.)     SI  25. 


aJND  scientific  publications. 


(Now  Comp/ete.) 

PEREIRA  (JONATHAN),  M.  D.,  F.  R.  S.,  AND  L.  S. 

THE    ELEMENTS    OF    MATERIA    MEDICA    AND    THERAPEUTICS. 

Third  American  edition,  enlarged  and  improved  by  the  author;  including  Notices  of  most  of  the 
Medicinal  Substances  in  use  in  the  civilized  world,  and  forming  an  Encyclopaedia  of  Materia 
Medica.  Edited,  with  Additions,  by  Joseph  Carson,  M.  D.,  Professor  of  Materia  Medica  and 
Pharmacy  in  the  University  of  Pennsylvania.  In  two  very  large  octavo  volumes  of  2100  pages, 
on  small  type,  with  about  500  illustrations  on  stone  and  wood,  strongly  bound  in  leather,  with 
raised  bands.     $9  00. 

Gentlemen  who  have  the  first  volume  are  recommended  to  complete  their  copies  without  delay. 

Price  of  Vol.  II.  $5  00. 

and  to  the  directions  of  the  United  States  Pharma- 
copoeia, in  connect  ion  with  all  the  articles  contained 
in  the  volume  which  are  referred  toby  it  The  il- 
lustrations have  been  increased,  and  this  edition  by 
Dr.  Carson  cannot  well  be  regarded  in  any  other 
light  than  that  of  a  treasure  which  should  be  found 
in  the  library  of  every  physician. — New  York  Journ- 
al of  Medical  and  Collateral  Science. 

The  work,  in  its  present  shape,  forms  the  most 
comprehensive  and  complete  treatise  on  materia 
medica  extant  in  the  English  language.  The  ac- 
counts of  the  physiological  and  therapeutic  effects 
of  remedies  are  given  with  great  clearness  and  ac- 
curacy, and  in  a  manner  calculated  to  interest  as 
well  as  instruct  the  reader. —  Edinburgh  Medical 
and  Surgical  Journal. 


The  first  volume  will  no  longer  be  sold  separate. 

The  third  edition  of  his  "  Elements  of  Materia 
Medica,  although  completed  under  the  supervision  of 
others,  is  by  far  the  most  elaborate  treatise  in  the 
English  language, and  will,  while  medical  literature 
is  cherished,  continue  a  monument  alike  honorable 
to  his  genius,  as  to  his  learning  and  industry. — 
American  Journal  of  Pharmacy. 

Our  own  opinion  of  its  merits  is  that  of  its  editors, 
and  also  that  of  the  whole  profession,  both  of  this 
and  foreign  countries— namely,  "  that  in  copious- 
ness of  details,  in  extent,  variety,  and  accuracy  of 
information,  and  in  lucid  explanation  of  difficult 
and  recondite  subjects,  it  surpasses  all  other  works 
on  Materia  Medica  hitherto  published."  We  can- 
not close  this  notice  without  alluding  to  the  special 
additions  of  the  A  merican  editor,  which  pertain  to 
the  prominent  vegetable  productions  of  this  country, 


PEASLEE   (E.  R.),   M .  D., 

Professor  of  Physiology  and  General  Pathology  in  the  New  York  Medical  College. 

HUMAN  HISTOLOGY,  in  its  relations  to  Anatomy,  Physiology,  and  Pathology; 

for  the  use  of  Medical  Students.     With  four  hundred  and  thirty-four  illustrations.     In  one  hand- 
some octavo  volume,  of  over  600  pages.     (Now  Ready.)     $3  75. 

The  rapid  advances  made  of  late  years  in  our  knowledge  of  the  structure  and  functions  of  the 
elements  which  constitute  the  human  body,  have  rendered  the  subject  of  Histology  of  fhe  highest 
importance  to  all  who  regard  medicine  as  a  science.  At  the  same  time,  the  vast  body  of  facta 
covered  by  Physiology  has  caused  our  text-books  on  that  subject  to  be  necessarily  restricted  in 
their  treatment  of  the  portions  devoted  to  Histology.  A  want  has,  therefore,  arisen  of  a  w  irk  de- 
moted especially  to  the  minute  anatomy  of  the  body,  giving  a  complete  and  detailed  account  of  the 
structure  of  the  various  tissues,  as  well  as  the  solids  and  fluids,  in  all  the  different  organs — their 
functions  in  health,  and  their  changes  in  disease.  In  undertaking  this  task,  the  author  has  endea- 
vored to  present  his  extensive  subject  in  the  manner  most  likely  to  interest  and  benefit  Ibe  physician, 
confident  that  in  these  details  will  be  found  the  basis  of  true  medical  science.  The  very  large 
number  of  illustrations  introduced  throughout,  serves  amply  to  elucidate  the  text,  while  the  typo- 
graphy of  the  volume  will  in  every  respect  be  found  of  the  handsomest  description. 

It  embraces  a  library  upon  the  topics  discussed  |  into  a  harmonious  whole.  We  commend  t  le  work- 
within  itself,  and  is  just  what  the  teacher  and  learner 
need.  Another  advantage,  by  no  means  to  be  over- 
looked, everything  of  real  value  in  the  wide  range 
which  it  embraces,  is  with  great  skill  compressed 
into  an  octavo  volume  of  but  little  more  than  six 
hundred  pages.  We  have  not  only  the  whole  sub- 
ject o(  Histology,  interesting  in  itself,  ably  and  fully 
discussed,  but  what  is  of  infinitely  greater  interest 
to  the  student,  because  of  greater  practical  value, 
are  its  relations  to  Anatomy,  Physiology,  and  Pa- 
thology, which  are  here  fully  and  satisfactorily  set 
forth.  These  great  supporting  branches  of  practical 
medicine  are  thus  linked  together,  and  while  estab- 
lishing and  illustrating  each  other,  are  interwoven 


to   students  and  physicians  generally.  —  Nashville 
Joum.  of  Med.  and  Surgery,  Dec.  18 

It  far  surpasses  our  expectation.  We  never  con- 
ceived the  possibility  of  compressing  so  much  valu- 
able information  into  so  compact  a  form.  We  will 
not  consume  space  with  commendations.  We  re- 
ceive this  contribution  to  physiological  science, 
"  Not  with  vain  thanks,  but  with  acceptance  boun- 
teous." We  have  already  paid  it  the  practical 
compliment  of  making  abundant  use  of  it  in  the 
preparation  of  our  lectures,  and  also  of  recommend- 
ing its  further  perusal  most  cordially  to  our  alumni; 
a  recommendation  which  we  now  extend  to  our 
readers. — Memphis  Med.  Recorder,  Jan.  1S53. 


PIRRIE  (WILLIAM),  F.  R.  S.  E., 

Professor  of  Surgery  in  the  University  of  Aberdeen. 

THE    PRINCIPLES  AND  PRACTICE  OP  SURGERY.    Edited  by  John 

Neill,  M.  D.,  Professor  of  Surgerv  in  the  Penna.  Medical  College,  Surgeon  to  the  Pennsylvania 

Hospital,  &c.   In  one  very  handsome  octavo  volume,  leather,  of  780  pages,  with  316  illustrations. 

$3  75. 

We  know  of  no  other  surgical  work  of  a  reason- 
able size,  wherein  there  is  so  much  theory  and  prac- 
tice, or  where  subjects  are  more  soundly  or  clearly 
taught. — The  Stethoscope. 

There  is  scarcely  a  disease  of  the  bones  or  soft 
parts,  fracture,  or  dislocation,  that  is  not  illustrated 
by  accurate  wood-engravings.  Then,  again,  every 
instrument  employed  by  the  surgeon  is  thus  repre- 
sented. These  engravings  are  not  only  correct,  but 
really  beautiful,  showing  the  astonishing  degree  of 
perfection  to  which  the  art  of  wood-engraving  has 


arrived.  Prof.  Pirrie,  in  the  work  before  us,  haa 
elaborately  discussed  the  principles  of  surgery,  and 
a  safe  and  effectual  practice  predicated  upon  them. 
Perhaps  no  work  upon  this  subject  heretofore  issued 
is  so  full  upon  the  science  of  the  art  of  surgery. — 
Nashville  Journal  of  Mtdicine  and  Surgery. 

One  of  the  best  treatises  on  surgery  in  the  English 
language. — Canada  Med.  Journal. 

Our  impression  is,  that,  as  a  manual  for  students, 
Pirrie's  is  the  best  work  extant. —  Western  Med.  and 
Surg.  Journal. 


PARKER   (LANGSTON), 

Surgeon  to  the  Queen's  Hospital,  Birmingham. 

THE  MODERN  TREATMENT  OP  SYPHILITIC  DISEASES,  BOTH  PRI- 
MARY AND  SECONDARY;  comprising  the  Treatment  of  Constitutional  and  Confirmed  Syphi- 
lis by  a  safe  and  successful  method.  With  numerous  Cases,  Formulas,  and  Clinical  Observa- 
tions: From  the  Third  and  entirely  rewritten  London  edition, 
extra  cloth,  of  316  pages.    $175. 


In  one  neat  octavo  volume, 


BLANCHAKI)  &  LEA'S  MEDICAL 


PARRISH    (EDWARD), 
Lactam  in  Practical  Pharmacy  and  Materie  Medics  in  the  Pennsylvania  Academy  of  Medicine,  &c. 

AN  INTRODUCTION  TO  PRACTICAL  PHARMACY.  Designed  as  a  Text- 
Book  lor  tin'  Student,  and  as  a  Guide  for  the  Physician  and  Pharmaceutist.  With  many  For- 
mulae and  Prescriptions.  In  one  handsome  oclavo  volume,  extra  cloth,  of  550  pages,  with  243 
Illostrat  .  7-">. 

A  careful  examination  of  this  work  enables  us  to  Medica;  it  familiarizes  liim  with  the  compounding 
..■I  it  in  the  highest  terms,  as  being  the  best  of  drags,  and  supplies  those  minntiss  whieh  but  few 
treatise  on  practical  pharmacy  with  which  we  are  practitioners  cun  impart.  The  junior  practitioner 
acquainted,  and  an  invaluable  oaeU  -mi  rum,  nol  only  will,  also,  find  this  volume  replete  with  i nut  ruction, 
to  the  apothecary  snd  >"  'hose  practitioners  Who  arc  — Charleston  Med.  Journal  and  H'  cf.tr,  Mar.  1^50. 
accustomed  to  prepare  their  own  medicines,  but  to  |      There  is  no  useful  information  in  the  details  of  the 


every  medical  man  and  medical  student  Through- 
oat  the  work  are  interspersed  valuable  tables,  useful 
formula:,  and  practical  hints,  and  the  whole  is  ill  US' 
:  by  a  large  number  of  excellent  wood-engrav- 
ings.— !■  I.  and  Surg.  Journal. 


apothecary's  or  country  physician's  office  conducted 
according  to  science  that  is  omitted.  The  young 
physician  will  find  it  an  encyclopedia  of  indispensa- 
ble medical  knowledge,  from  the  purchase  of  a  spa- 
tula to  the  compounding  of  the  most  learned  pre- 


Thia  is  altogether  one  of  the  most  useful  books  we  script  ions.  The  work  is  by  the  ablest  pharmaceutist 
have  seen.  It  is  just  what  we  have  long  felt  to  be  in  the  United  Slides,  and'  must  meet  with  an  im- 
needc.l  by  apothecaries,  students,  and  practitioners  ,  mense  sale. — JS'ashville  Journal  of  Medicine,  April, 
of  medicine,  most  of  whom  in  this  country  have  to    1S5G. 


put  up  their  own  prescriptions.  Itbears,  upon  every 
page,  the  impress  of  practical  knowledge,  conveyed  I 
tu  a  plain  common  sense  manner,  nnd  adapted  to  the 
comprehension  of  all  who  may  rend  it.  No  detail 
has  been  omitted,  however  trivial  it  may  seem,  al-  I 
though  really  important  to  thedispenser  of  medicine. 
— Southt  rn  Mtd.  and  Surg.  Journal. 

To  both  the  country  practitioner  and  the  city  apo-  j 
thecary  this  work  of  Mr.  Parrish  is  a  godsend.     A 
careful  study  of  its  contents  will  give  the  young 
graduate  a  familiarity  with  the  value  and  mode  of 


We  are  glad  to  receive  this  excellent  work.  It 
will  supply  a  want  long  felt  by  the  profession,  and 
especially  by  the  student  of  Pharmacy.  A  large 
majority  of  physicians  are  obliged  to  compound 
their  own  medicines,  and  to  them  o  work  of  this 
kind  is  indispensable. — N.  O.  Medical  and  Surgical 
Journal. 

AVe  cannot  say  but  that  this  volume  is  one  of  the 
most  welcome  and  appropriate  which  has  for  a  long 
time  been  issued  from  the  press.  It  is  a  work  which 
we  doubt  not  will  at  once  secure  an  extensive  cir- 


administering  his  prescriptions,  which  will  be  of  as  :  Cnlation,  as  it  is  designed  not  only  for  the  druggist 


much  use  to  his  patient  as  to  himself. —  Va.  Med. 
Journal. 

Mr.  Parrish  has  rendered  a  very  acceptable  service 


and  pharmaceutist,  but  also  for  the  great  body  of 
practitioners  throughout  the  country,  who  not  only 
have  to  prescribe  medicines,  but  in  the  majority  of 


to  the  practitioner  and  student,  by  furnishing  this  ,  instances  have  to  rely  upon  their  own  resources — 


book,  which  contains  the  leading  facts  and  principles 
of  the  science  of  Pharmacy,  conveniently  arranged 
for  study,  and  with  special  reference  to  those  features 
of  the  subject  which  possess  nn  especial  practical  in- 
terest to  the  physician.  It  furnishes  the  student,  at 
the  commencement  of  his  studies,  with  that  infor- 
mation which  is  of  the  greatest  importance  in  ini- 
tiating him  into  the  domain  of  Chemistry  and  Materia 


whatever  these  may  be — not  only  to  compound,  but 
also  to  manufacture  the  remedies  they  are  called 
upon  to  administer.  The  author  has  not  mistaken 
the  idea  in  writing  this  volume,  as  it  is  alike  useful 
and  invaluable  to  those  engaged  in  the  active  pur- 
suits of  the  profession,  and  to  those  preparing  to  en- 
ter upon  the  field  of  professional  labors. — American 
Lancet,  March  24,  185G. 


RICORD  ( 
A  TREATISE  ON  THE  VENEREAL 

Wilh  copious  Additions,  by  Ph.  Ricord,  M.  D. 
M.  D.    Iu  one  handsome  octavo  volume,  extra 

Every  one  will  recognize  the  attractiveness  and 
value  which  this  work  derives  from  ihus  presenting 
the  opinions  of  these  two  masters  side  by  side.  Bui, 
it  must  be  admitted,  what  has  made  the  fortune  of 
the  book,  is  the  fact  that  it  contains  the  "most  com- 
plete  embodiment  of  the  veritable  doctrines  of  the 
Hopital  du  Midi,"  which  has  ever  been  made  public. 
The  doctrinal  ideas  of  M.  Ricord,  ideas  which,  if  not 
universally  adopted,  are  incontestably  dominant,  have 
heretofore  only  been  interpreted  by  more  or  less  skilful 


P.),   M.  D., 

DISE  AS  K.     By  John  Hunter,  F.  R.  S. 

Edited,  with  Notes,  by  Freeman  J.  Bumstead, 
cloth,  of  520  pages,  with  plates.     $3  25. 

I  secretaries,  sometimes  accredited  and* sometime?  no'. 
In  the  notes  to  Hunter,  the  master  substitutes  him- 
selfforlns  interpreters,  and  give  6  hisoriginal  thought? 
to  the  world  in  a  lucid  and  perfectly  intelligible  man- 
ner. In  conclusion  we  can  say  that  ibis  is  incon- 
testably  the  best  treatise  on  syphilis  with  which  we 
are  acquainted,  and.  as  we  do  nol  often  employ  the 
phrase,  we  may  be  excused  for  expressin?  the  hope 
that  it  may  find  a  place  in  the  library  of  every  phy- 
sician.—  Virginia  Med.  and  Surg.  Journal. 


BY    THE   SAME   AUTHOR. 


ILLUSTRATIONS  OF  SYPHILITIC  DISEASE. 
Translated  by  Thomas  F.  Bettox,  M.  D.  With 
fifty  large  quarto  colored  plates.  In  one  large 
quarto  volume,  extra  cloth.     $15  00. 


LETTERS  ON  SYPHILIS,  addressed  to  the  Chiet 
Editor  of  the  Union  Medicale.  Translated  by  W. 
P.  Lattimore,  M.  D.  In  one  neat,  octavo  vol- 
ume, of  270  pages,  extra  cloth.    $2  00. 


RIGBY    (EDWARD),    M.  D., 
Senior  Physician  to  the  General  Lying-in  Hospital,  &c. 

A    SYSTEM    OF    MIDWIFERY.     With  Notes  and  Additional  Illustrations. 

Second  American  Edition.     One  volume  octavo,  extra  cloth,  422  pages.     $2  50. 
by  the  same  author.     (Now  Ready,  1857.) 

ON  TnE  CONSTITUTIONAL  TREATMENT  OF  FEMALE  DISEASES. 

In  one  neat  royal  12mo.  volume,  extra  cloth,  of  about  250  pages.     $1  00. 

The  aim  of  the  author  has  been  throughout  to  present  sound  practical  views  of  the  important 
subjects  under  consideration  ;  and  without  entering  into  theoretical  disputations  and  disquisitions  to 
embody  the  results  of  his  long  and  extended  experience  in  such  a  condensed  form  as  would  be 
easily  accessible  to  the  practitioner. 


T»     11. 1     III',..    ,       ..~..       .... —  J ~« ~..,    «._.    _•-■  -  .      . 

In  one  large  octavo  volume,  extra  cloth,  of  about  700  pages.     $3  00 


the 

States. 

(ration*. 


AND    SCIENTIFIC    PUBLICATIONS. 


27 


RAMSBOTHAM  (FRANCIS   H.),   M.D. 
THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRIC  MEDICINE  AND 

SURGERY,  in  reference  to  the  Process  of  Parturition.  A  new  and  enlarged  edition,  thoroughly 
revised  by  the  Author.  W  ith  Additions  by  W.  V.  Keating,  M.  D.  In  one  large  and  handsome 
imperial  octavo  volume,  ol  050  pages,  strongly  bound  in  leather,  with  raised  bands;  with  sixty- 
lour  beautiful  Plates,  and  numerous  Wood-cuts  in  the  text,  containing  in  all  nearly  two  hundred 
large  and  beautiful  figures.    (Lately  Issued,  1856.)  $5  00. 

In  calling  the  attention  of  the  profession  to  the  new  edition  of  this  standard  work,  the  publishers 
would  remark  that  no  efforts  have  been  spared  to  secure  for  it  a  continuance  and  extension  of  the 
remarkable  favor  with  which  it  has  been  received.  The  last  London  issue,  which  was  considera- 
bly enlarged,  has  received  a  further  revision  from  the  author,  especially  for  this  country.  It-  pas- 
sage through  the  press  here  has  been  supervised  by  Dr.  Keating,  who  has  made  numerous  addi- 
tions with  a  view  of  presenting  more  fully  whatever  was  necessary  to  adapt  it  thoroughly  to 
American  modes  of  practice.  In  its  mechanical  execution,  n  like  superiority  over  former  editions 
will  be  found. 

From  Prof.  Hodge,  of  the  University  of  Pa. 

To  the  American  public,  it  is  most  valuable,  from  its  intrinsic  undoubted  excellence,  and  as  beinu 
the  best  authorized  exponent  of  British  Midwifery.  Its  circulation  will,  I  trust,  be  extensive  throughout 
our  country.  ° 

cine  and  Surgery  to  our  library,  and  confidently 
recommend  it  to  our  readers,  with  the  assurance 
that  it  will  not  disappoint  their  most  sanguine  ex- 
pectations.—  Western  Lancet. 


our  country 

The  publishers  have  shown  their  appreciation  of 
the  merits  of  this  work  and  secured  its  success  by 
the  truly  elegant  style  in  which  they  have  brought 
it  out,  excelling  themselves  in  its  production,  espe- 
cially in  its  plates.  It  is  dedicated  to  Prof.  Meigs, 
and  has  the  emphatic  endorsement  of  Prof.  Hodge, 
as  the  best  exponent  of  British  Midwifery.  We 
know  of  no  text-hook  which  deserves  in  all  respects 
to  be  more  highly  recommended  to  students,  and  we 
could  wish  to  see  it  in  the  hands  of  every  practitioner, 
for  they  will  find  it  invaluable  for  reference. — Med. 
Gazette. 

But  once  in  a  long  time  some  brilliant  genius  rears 
his  head  above  the  horizon  of  science,  and  illumi- 
nates and  purifies  every  department  that  he  investi- 
gates ;  and  his  works  become  types,  by  which  innu- 
merable imitators  model  their  feeble  productions. 
Such  a  genius  we  find  in  the  younger  Ramsbotham, 
and  such  a  type  we  find  in  the  work  now  before  us. 

The  binding,  paper,  type,  the  engravings  and  wood-  i  work  are  so  well  known  and  thoroughly  established! 
cuts  are  all  so  excellent  as  to  make  this  book  one  of    that  comment  is  unnecessary  and  praise  superfluous. 

■    The  illustrations,  which  are  numerous  and  accurate, 
are  executed  in  the  highest  style  of  art.     We  cannot 

too  highly  recommend  the  work  to  our  readers. St. 

Louis  Med.  and  Surg.  Journal. 


It  is  unnecessary  to  say  anything  in  regard  to  the 
utility  of  this  work.  It  is  already  appreciated  in  our 
country  for  the  value  of  the  matter,  the  clearness  of 
its  style,  and  the  fulness  of  its  illustrations.  To  the 
physician's  library  it  is  indispensable,  while  to  the 
student  as  a  text- book,  from  which  to  extract  the 
material  for  laying  the  foundation  of  an  education  on 
obstetrical  science,  it  has  no  superior. — Ohio  Med. 
and  Surg.  Journal. 

We  will  only  add  that  the  student  will  learn  from 
it  all  he  need  to  know,  and  the  practitioner  will  find 

it,  as  a  book  of  reference,  surpassed  by  none  other. 

Stethoscope. 

The  character  and  merits  of  Dr.  Ramshotham'g 


the  finest  specimens  of  the  art  of  printing  that  have 
given  such  a  world-wide  reputation  to  irs  enter- 
prising and  liberal  publishers.  We  welcome  Rams- 
botham's  Principles  and  Practice  of  Obstetric  Medi- 


ROKITANSKY   (CARL),    M.D., 

Curator  of  the  Imperial  Pathological  Museum,  and  Professor  at  the  University  of  Vienna,  &c 

A    MANUAL   OF  PATHOLOGICAL    ANATOMY.     Four  volumes,   octavo, 

bound  in  two,  extra  cloth,  of  about  1200  pages.     Translated  by  W.  E.  Swaine,  Edward  Sieve- 
king,  C.  H.  Moore,  and  G.  E.  Day.     (Just  Issued.)    $5  50 
To  render  this  large  and  important  work  more  easy  of  reference,  and  at  the  same  time  less  cum- 
brous and  costly,  the  four  volumes  have  been  arranged  in  two,  retaining,  however,  the  separale 
paging,  &c. 

The  publishers  feel  much  pleasure  in  presenting  to  the  profession  of  the  United  States  the  great 
work  of  Prof.  Rokitansky,  which  is  universally  referred  to  as  the  standard  of  authority  by  the  pa- 
thologists of  all  nations.  Under  the  auspices  of  the  Sydenham  Society  of  London,  the  combined 
labor  of  four  translators  has  at  length  overcome  the  almost  insuperable  difficulties  which  have  - 
long  prevented  the  appearance  of  the  work  in  an  English  dress.  To  a  work  so  widely  known, 
eulogy  is  unnecessary,  and  the  publishers  would  merely  state  that  it  is  said  to  contain  the  results 
of  not  less  than  thirty  thousand  post-mortem  examinations  made  by  the  author,  diligently  com- 
pared, generalized,  and  wrought  into  one  complete  and  harmonious  system. 


The  profession  is  too  well  acquainted  with  the  re- 
putation of  Rokitansky's  work  to  need  our  assur- 
ance that  this  is  one  of  the  most  profound,  thorough, 
and  valuable  books  ever  issued  from  the  medical 
press.  It  is  sui  generis,  and  has  no  standard  of  com- 
parison. It  is  only  necessary  to  announce  that  it  is 
issued  in  a  form  as  cheap  as  is  compatible  with  its 
size  and  preservation,  and  its  sale  follows  as  a 
matter  of  course.  No  library  can  be  called  com- 
plete without  it. — Buffalo  Med.  Journal. 

An  attempt  to  give  our  readers  any  adequate  idea 
of  the  vast  amount  of  instruction  accumulated  in 
these  volumes,  would  be  feeble  and  hopeless.  The 
effort  of  the  distinguished  author  to  concentrate 
in  a  small  space  his  great  fund  of  knowledge,  has  I  Am.  Med.  Monthly. 


so  charged  his  text  with  valuable  truths,  that  any 
attempt  of  a  reviewer  to  epitomize  is  at  once  para- 
lyzed, and  must  end  in  a  failure. —  Western  Lancet. 
As  this  is  the  highest  source  of  knowledge  upon 
the  important  subject  of  which  it  treats, "no  real 
student  can  afford  to  be  without  it.  The  American 
publishers  have  entitled  themselves  to  the  thanks  of 
the  profession  of  their  country,  for  this  timeoua  and 
beautiful  edition. — Nashville  Journal  oj'  Mtdicint. 

As  a  book  of  reference,  therefore,  this  work  inns* 
prove  of  inestima  hie  value,  and  we  cannot  too  highly 
recommend  it  to  the  profession. —  Charleston  Med. 
Journal  and  Review,  Jan.  1856. 

This  book  is  a  necessity  to  every  practitioner. — 


SCHOEDLER  (FRIEDRICH),   PH.D., 

Professor  of  the  Natural  Sciences  at  Worms,  <kc. 

THE   BOOK   OF  NATURE;   an  Elementary  Introduction  to  the  Sciences  of 

Physics,  Astronomy,  Chemistry,  Mineralogy,  Geology,  Botany,  Zoology,  and  Physiology.  First 
American  edition,  with  a  Glossary  and  other  Additions  and  Improvements;  from  the  second 
English  edition.  Translated  from  the  sixth  German  edition,  by  Henry  Mkdlock,  F.  C.  S.,  &c. 
In  one  volume,  small  octavo,  extra  cloth,  pp.  692,  with  679  illustrations.     $1  80. 


29 


BL  A  \  en  .\  15  I)    \-    LEA'S    MEDICAL 


SMITH    (HENRY    H.),    M.  D., 
Professor  of  Surgery  in  the  University  of  Pennsylvania,  See. 

MINOR  BUKGERYj  or.  Hints  on  the  Every-day  Duties  of  the  Surgeon, 
tratcd  by  two  hundred  ;ui<l  forty-seven  illustrations.    Third  and  enlarged  edition 
Borne  royal  l2mo.  volume,    pp.  456.    In  leather,  52  2-r>;  extra  cloth,  $2  00. 
And  a  capital  little  book  it  is.  .  ■  Minor  Surgery, 

we  repeat,  is  really  Major  Surgery,  and  anyl 

which  teaches  h  is  worth  having.    So  we  cordially 

recommend  this  little  book  of  Dr.  Smith's.—  Aferf.- 

fair .    /;.  oil  W. 

This  beautiful  little  work  has  been railed  with 

a  view  to  the  waata  of  the  profession  in  the  matter 
0f  ba  be, and  well  and  ably  lias  the  author 

performed  Bib  labors.  Well  adapted  to  give  the 
requisite  information  on  the  subjects  of  which  it 
.  — Medical  Ezamiiu r. 

The  directions  arc  plain,  and  illustrated  through- 
nut  with  clear  engravings. — London  Lancet. 

One  of  the  best  works  they  can  consult  on  the 
■nbjeel  <>l"  which    it    treats. — Southern  Journal  of  I  works. 


Illus- 

ln  one  liund- 

A  work  such  as  the  present  is  therefore  highly 
useful   to  the  stndent,  and  we  commend   tins  one 

to    their   attention. — American  Journal  of  M-dicul 
Seu  nces. 

No  operator,  however  eminent,  need  hesitate  to 
consul!  this  unpretending  yet  exoellenl  book.  Those 
who  are  young  in  the  business  would  Bad  Dr.  Smith's 
treatise  s  necessary  companion,  alter  once  under- 
standing its  true  character. — Boston  Med.  and  Surg. 
Journal. 

\o  young  practitioner  should  be  without  this  little. 

volume  ;  and  we  venture  to  assert,  that  it  maybe 

a  insulted  by  the  senior  members  of  the  profession 

with  more  real  benefit,  than  the  more  voluminous 

Western  Lancd. 


int  and  Pharmacy. 


BY   THE   SAME   AUTHOR,   AND 

HORNER  (WILLIAM   E.),    M.D. 


Late  Professor  of  Anatomy  in  the  University  of  Pennsylvania. 

AN  ANATOMICAL  ATLAS,  illustrative  of  the  Structure  of  the  Human  Body. 

In  one  volume,  large  imperial  octavo,  extra  cloth,  with  about  six  hundred  and  fifty  beautiful 

figures.     $3  00. 

These  figures  are  well  selected,  and  present  a  late  the  student  upon  the  completion  of  this  Atlas, 
Complete  and  accurate  representation  of  that  won-  as  it  is  the  most  convenient  work  of  the  kind  that 
derful  fabric,  the  human  body.  The  plan  of  this  has  yet  appeared  ;  and  we  must  add,  the  very  beau- 
Atlas,  which  renders  it  so  peculiarly  convenient  tiful  manner  in  which  it  is  "  got  up"  is  so  creditable 
for  the  student,  and  its  superb  arlistieiil  execution,  to  the  country  as  to  be  flattering  to  our  national 
have  been  already  pointed  out.     We  must  congratu-  |  pride. — American  Medical  Journal. 


SARGENT  (F.  W.),   M .  D. 
ON  BANDAGING  AND  OTHER  OPERATIONS  OF  MINOR  SURGERY. 

Second  edition,  enlarged.     One  handsome  royal  12mo.  vol.,  of  nearly  400  pages,  with  182  wood- 
cuts.    Extra  cloth,  $1  40;  leather,  $1  50. 


This  very  useful  little  work  has  long  been  a  favor- 
ite with  practitioners  and  students.  The  recent  call 
for  a  new  edition  has  induced  its  author  to  make 
numerous  important  additions.  A  slight  alteration 
in  the  size  of  the  page  has  enabled  liiiu  to  introduce 
the  new  matter,  to  the  extent  of  some  fifty  pages  of 
the  former  edition,  at  the  same  time  that  his  volume 
is  rendered  still  more  compact  than  its  less  compre- 
hensive predecessor.  A  double  gain  in  thus  effected, 
which,  in  a  vade-mecum  of  this  kind,  is  a  material 
improvement. — Am.  Medical  Journal. 

Sargent's  Minor  Surgery  has  always  been  popular, 
and  deservedly  so.  It  furnishes  that  knowledge  of  the 
most  frequently  requisite  performances  of  surgical 
art  which  cannot  he  entirely  understood  by  attend- 
ing clinical  lectures.  The  art  of  bandaging,  which 
is  regularly  taught  in  Europe,  is  very  frequently 
overlooked  by  teachers  in  this  country;  the  student 
and  junior  practitioner,  therefore,  may  often  require 
that  knowledge  which  this  little  volume  so  tersely 
and  happily  supplies.     It  is  neatly  printed  and  copi- 


ously illustrated  by  the  enterprising  publishers,  and 
should  be  possessed  by  till  who  desire  Vo  he  thorough- 
ly conversant  with  the  details  of  this  branch  of  our 
art. — Charleston  Med.  Journ.  and  Hevieio,  March, 
1856. 

A  work  that  has  been  so  long  and  favorably  known 
to  the  profession  as  Dr.  Sargent's  Minor  Surgery, 
needs  no  commendation  from  us.  We  would  remark, 
however,  in  this  connection,  that  minor  surgery  sel- 
dom gets  that  attention  in  our  schools  that  its  im- 
portance deserves.  Our  larger  works  are  also  v< 
defective  in  their  teaching  on  these  small  practical 
points.  This  little  book  will  supply  the  void  which 
all  must  feel  who  have  not  studied  its  pages. —  West- 
em  Lancet,  March,  1856. 

We  confess  our  indebtedness  to  this  little  volume 
on  many  occasions,  and  can  warmly  recommend  it 
to  our  readers,  as  it  is  not  above  the  consideration 
of  the  oldest  and  most  experienced. — American  Lan- 


SKEY'S  OPERATIVE  SURGERY.  In  one  very 
handsome  octavo  volume,  extra  cloth,  of  over  050 
pages,  with  about  one  hundred  wood-cuts.   $3  25. 

STANLEY'S   TREATISE    ON    DISEASES    OF 
THE  HONES, 
286  pages.    $1  50. 

SOU. YON  THE  HUMAN  BRAIN;  its  Structure, 
Physiology,  and  Diseases.     From  the  Second  and 


I  none  volume,  octavo,  extra  cloth, 


much  enlarged  London  edition.  In  one  octavo 
volume,  extra  cloth,  of  500  pages,  with  120  wood- 
cuts.    $2  00. 

SIMON'S  GENERAL  PATHOLOGY,  as  conduc- 
ive to  the  Establishment  of  Rational  Principles 
for  the  prevention  and  Cure  of  Disease.  In  one 
neat  octavo  volume,  extra  cloth,  of  212  pages. 
SI  25. 


STILLE  (ALFRED),   M.  D. 
PRINCIPLES    OF    GENERAL    AND    SPECIAL    THERAPEUTICS      In 

handsome  octavo.     {Preparing.) 

SIBSON   (FRANCIS),    M.D., 

Physician  to  St.  Mary's  Hospital. 

MEDICAL  ANATOMY.     Illustrating  the  Form,  Structure,  and  Position  of  the 

Internal  Organs  in  Health  and  Disease.     In  large  imperial  quarto,  with  splendid  colored  plates. 
To  match  "Maclise's  Surgical  Anatomy."    Part  I.     (Preparing.) 


AND    SCIENTIFIC    PUBLICATIONS. 


29 


SHARPEY  (WILLIAM),    M.  D.,    JONES    QUAIN,    M.  D.,   AND 

RICHARD   QUAIN,    F.  R:  S.,  &c. 

HUMAN  ANATOMY.     Revised,  with  Notes  and  Additions,  by  Joseph  Leidy 

M.  D.,  Professor  of  Anatomy  in  the  University  of  Pennsylvania.     Complete  in  two  large  octai  o 
I~!^*'_.  *_ —>°  *   .<!  xhn^n  huildred  pages.    Beautifully  illustrated  with  over  five  hundred 


engravings  on  wood.     SO  00. 

It  is  indeed  a  work  calculated  to  make  an  era  in 
anatomical  study,  by  placing  before  the  student 
every  department  of  his  science,  with  a  view  to 
the  relative  importance  of  each  ;  and  so  skilfully 
have  the  different  parts  been  interwoven,  that  no 
one  who  makes  this  work  the  basis  of  his  studies, 
will  hereafter  have  any  excuse  for  neglecting  it 
undervaluing  any  important  particulars  connected 
with  the  structure  of  the  human  frame;  and 
whether  the  bias  of  his  mind  lead  him  in  a  more 
especial  manner  to  surgery,  physic,  or  physiology, 


he  will  find  here  a  work  at  once  so  comprehensive 
and  practical  as  to  defend  him  from  exclusiveness 

on    the   one    hand,    and    pedantry    00     t  i her. 

Journal   and    Retrospect  of  ike   Midi  ces. 

We  have  no  hesitation  in  recommending  tins  trea- 
tise on  anatomy  as  the  most  complete  on  that  sub- 
ject in  the  English  language:  and  the  only  one, 
perhaps,  in  any  language,  which  brings  the  b 
of  knowledge  forward  to  the  most  recent  disco- 
veries.— The  Edinburgh.  Med.  and  Surg.  Journal. 


OF 


SMITH   (W.   TYLER),  M.  D., 
Physician  Accoucheur  to  St.  Mary's  Hospital,  &c. 

ON   PARTURITION,    AND    THE    PRINCIPLES    AND    PRACTICE 

OBSTETRICS.    In  one  royal  12mo.  volume,  extra  cloth,  of  400  pages.     SI  25. 

BY  THE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  ON  THE  PATHOLOGY  AND  TREATMENT 

OF  LEUCORRHCEA.     With  numerous  illustrations.     In  one  very  handsome  octavo  volume, 
extra  cloth,  of  about  250  pages.     SI  50. 

We  hail  the  appearance  of  this  practical  and  invaluable  work,  therefore,  as  a  real   acquisition  to  our 
medical  literature. — Medical  Gazette. 


TAYLOR  (ALFRED  S.),  M.  D.,  F.  R.  S., 

Lecturer  on  Medical  Jurisprudence  and  Chemistry  in  Guy's  Hospital. 

MEDICAL  JURISPRUDENCE.     Fourth  American,  from  the  fifth  improved  and 

enlarged  English  Edition.  With  Notes  and  References  to  American  Decisions,  by  Edward 
Hartshorne,  M.  D.  In  one  large  octavo  volume,  leather,  of  over  seven  hundred  pa°-es  (Just 
Issued,  1856.)     $3  00.  f  o   -      k 

This  standard  work  has  lately  received  a  very  thorough  revision  at  the  hands  of  the  author,  who 
has  introduced  whatever  was  necessary  to  render  it  complete  and  satisfactory  in  carrying  oul 
objects  in  view.  Ttie  editor  has  likewise  used  every  exertion  to  make  it  equally  thorough  wiih 
regard  to  all  matters  relating  to  the  practice  of  this  country.  In  doing  this,  he  has  carefully  ex- 
amined all  that  has  appeared  on  the  subject  since  the  publication  of  the  last  edition,  and  has  incorpo- 
rated all  the  new  information  thus  presented.  The  work  has  thus  been  considerably  increased  in 
size,  notwithstanding  which,  it  has  been  kept  at  its  former  very  moderate  price,  and  in  every  respect 
it  will  be  found  worthy  of  a  continuance  of  the  remarkable  favor  which  has  carried  it  throus 
many  editions  on  both  sides  of  the  Atlantic.    A  few  notices  of  the  former  editions  are  appended. 

we  do  not  hesitate  to  affirm  that  after  having  once 
commenced  its  perusal,  i'kw  could  be  prevailed  0 
to  desist  before  completing  it.  In  the  last  London 
edition,  all  the  newly  observed  and  accurately  re- 
corded facts  have  been  inserted,  including  much  that 
is  recent  of  Chemical,  Microscopical,  and  Patholo- 
gical research,  besides  papers  on  numerous  subjects 
never  before  published  .-Charleston  Medical  Journal 
and  Review. 


We  know  of  no  work  on  Medical  Jurisprudence 
which  contains  in  the  same  space  anything  like  the 
same  amount  of  valuable  matter. — N.  Y.  Journal  of 
Medicine. 

No  work  upon  the  subject  can  be  put  into  the 
hands  of  students  either  of  law  or  medicine  which 
will  engage  them  more  closely  or  profitably;  and 
none  could  be  oflered  to  the  busy  practitioner  of 
either  calling,  for  the  purpose  of  casual  or  hasty 
reference,  that  would  be  more  likely  to  afford  tlie  aid 
desired.     We  therefore  recommend  it  as  the  best  and 


It  is  not  excess  of  praise  to  say  that  the  volume 

before  us  is  the  very  best  treatise  extant  on  Medical 

safest  manual  for  daily  use— American  Journal  oj    Jurisprudence.     In  saj  ing  this,  we  do  not  wish  to 


be  understood  as  detracting  from  the  merits  i 
excellent  works  of  Beck,  Ryan,  Traill,  tin 
others;  but  in  interest  and  value  we  think  it  must 
be  conceded  that  Taylor  is  superior  to  anything  that 
has  preceded  it. — A'.  W.  Medical  and  Surg.  Journal. 


Medical  Sciences. 

This  work  of  Dr.  Taylor's  is  generally  acknow- 
ledged to  be  one  of  the  ablest  extant  on  the  subject 
of  medical  jurisprudence.  It  is  certainly  one  of  the 
most  attractive  books  that  we  have  met  with;  sup- 
plying so  much  both  to  interest  and  instruct,  that 

BY   THE    SAME   AUTHOR. 

ON  POISONS,  IN  RELATION  TO   MEDICAL  JURISPRUDENCE   AND 

MEDICINE.  Edited,  with  Notes  andAdditions,  by  R.  E.  Griffith,  M.  L>.  In  one  large  octavj 
volume,  leather,  of  6SS  pages.     S3  00 

TANNER   (T.    H.)f    M.  D., 

Physician  to  the  Hospital  for  Women,  &c. 

A  MANUAL  OF  CLINICAL  MEDICINE  AND  PHYSICAL  DIAGNOSIS. 

To  which  is  added  The  Code  of  Ethics  ol  the  American  Medical  Association.  Second 
American  Edition.  In  one  neat  volume,  small  12mo.  Price  iu  extra  cloth,  87|  cents  ;  flexible 
style,  for  the  pocket,  SO  cents. 


The  work  is  an  honor  to  its  writer,  and  must  ob- 
tain a  wide  circulation  by  its  intrinsic  merit  alone. 
Suited  alike  to  the  wants  of  students  and  practi- 
tioners, it  has  only  to  be  seen,  to  win  for  itself  a 
place  upon  the  shelves  of  every  medical  library. 
Xor  will  it  be  "  shelved"  long  at  a  time  ;  if  we  mis- 
take not,  it  will  be  found,  in  the  best  sense  of  the 


homely  but  expressive  word,  "  handy."  The  style 
is  admirably  clear,  while  it  is  so  sententious  as  not 
m  harden  the  memory.  Tlie  arrangement  is,  to  our 
mind,  unexceptionable.  The  work,  in  short,  de- 
serves the  heartiest  commendation.— Boston  Med. 
and  Surg.  Journal. 


30 


BLANCH  AKD    &    LEA'S    MEDICAL 


Now  Complete  (April,  1857.) 

TODD  (ROBERT   BENTLEYi,   M.  D.,   F.  R.  S., 

Profeuoi  ol  Physiology  in  King's  College,  London;  and 

WILLIAM    BOWMAN,   F.  R.  S., 

Demonstrator  of  Anatomy  in  King'i  College,  London. 

THK  PHYSIOLOGICAL  ANATOM?  AND  PHYSIOLOGY  OF  MAN.    With 

about  three  hundred  large  and  beautiful  illustrations  oa  wood.    Complete  in  one  large  octavo 

vol ,  of  ''in  pages,  leather.     Price  1 1  50. 

The  very  greal  delay  which  has  occurred  in  the  completion  of  this  work  has  arisen  from  the  de- 
sire  of  the  authors  to  verify  by  their  own  examination  ihe  various  questions  and  statements  pre- 
tented,  thus  rendering  the  work  one  of  peculiar  value  and  authority.  By  the  wideness  ol  its  Bcope 
and  the  accuracy  of  its  facts  it  thus  occupies  a  position  of  its  own,  and  becomes  necessary  to  all 
physiological  students. 

fey  Gentlemen  who  have  received  portions  of  this  work,  as  published  in  the  "  Medical  News 
ahd  Library,"  can  now  complete  their  copies,  it'  immediate  application  be  made.  It  will  be  fur- 
nished as  follows,  free  by  mail,  in  paper  covers,  with  cloth  backs. 

Paets  [.,  n.,  III.  (pp.  25  to  552),  $2  50. 

PART  IV.  (pp.  '>•'>'(  to  end.  with  Title,  Preface,  Contents,  ire),  S2  00. 

Or,  PART  IV..  SeCTIOH  II.  (pp.  725  to  end,  with  Title,  Preface,  Contents,  ecc),  $1  25. 

A  magnificent  contribution  to  British  medicine,  i  One  of  the  very  best  books  ever  issued  from  any 
and  the  American  physician  who  shall  fail  topeiuse    medical  press.    We  think  it  indispensable  to  every 


it,  Will  have  failed  to  read  one  of  the  most  instruc 
tive  books  of  the  nineteenth  century. — If.  O.  Med 
and  Surg.  Journal,  Sept.  1857. 

It  is  more  concise  than  Carpenter's  Principles,  and 
more  modern  than  the  accessible  edition  of  Mailer's 
Elements;  Us  details  are  brief,  but  sufficient;  its 
descriptions  vivid  ;  its  illustrations  exact  and  copi- 
ous ;  and  its  language  terse  and  perspicuous. — 
Charleston  Med.  Journal,  July,  1857. 

We  recommend  this  work  not  only  for  its  many 
origiral  investigations  especially  into  the  minute 
anatomy  and  physiology  of  man,  but  we  ndmire  the 
constant  association  of  anatomy  with  physiology. 
The  motive  power  is  studied  in  its  connections  and 
adaptations  to  the  machine  it  is  destined  to  guide, 
and  the  student  feels  constantly  impressed  with  the 
necessity  for  an  accurate  knowledge  of  the  structure 
of  the  human  body  before  he  can  make  himself  mas- 
ter of  its  functions. —  Va.  Med.  Journal,  June,  1857. 

We  know  of  no  work  on  the  subject  of  physiology 
so  well  adapted  to  the  wants  of  the  medical  student. 
Its  completion  has  been  thus  long  delayed,  that  the 
authors  might  secure  accuracy  by  personal  observa- 
tion.— St.  Louis  Med.  and  Surg.  Journal,  Sept.  '57. 


reading  medical  man,  and  it  may,  with  all  propriety, 
and  with  the  utmost  advantage  be  macea  text-book 
by  any  student  who  would  thoroughly  comprehend 
the  groundwork  of  medicine. — N.  O.  Med.  News, 
June,  1S57. 

Our  notice,  though  it  conveys  but  a  very  feeble 
and  imperfect  idea  of  the  magnitude  and  importance 
of  the  work  now  under  consideration,  already  tran- 
scends our  limits  ;  and,  with  the  indulgi  nee  of  our 
readers,  and  the  hope  that  they  will  peruse  the  book 
for  themselves,  as  we  feel  we  can  with  confidence 
recommend  it,  we  leave  it  in  their  hands  for  them 
to  judge  Of  its  merits.— The  Northwestern  Med.  and 
Surg.  Journal,  Oct.  Is57. 

It  has  been  a  far  more  pleasant  task  to  us  to  point 
out  its  features  of  remarkable  excellence,  and  to 
show  in  how  many  particulars  the  results  which  it 
embodies  of  skilful  and  zealous  research  do  the 
highest  credit  to  its  able  and  accomplished  authors. 
It  would  be  a  serious  omission  were  we  not  to  take 
special  notice  of  the  admirable  and  copious  illustra- 
tions, the  execution  of  which  (by  Mr.  Vasey)  is  in 
the  very  finest  style  of  wood-engraving.— Brit,  and 
For.  Medico-Chir.  Review,  Jan.  1858. 


TODD  (R.    8.),   M.  D.,    F.  R.  S.,   &c. 
CLINICAL  LECTURES  ON  CERTAIN   DISEASES  OF  THE  URINARY 

ORGANS  AND  ON  DROPSIES.     In  one  octavo  volume.    (Now  Ready,  1857.)     $1  50 
The  valuable  practical  nature  of  Dr.  Todd's  writings  have  deservedly  rendered  them  favorites 
with  Ihe  pro  ession,  and  the  present  volume,  embodying  the  medical  aspects  of  a  class  of  diseases 
not  elsewhere  to  be  found  similarly  treated,  can  hardly  fail  to  supply  a  want  long  felt  by  the  prac- 
titioner 


WATSON    (THOMAS),    M.D.,    &.C. 
LECTURES    ON    THE    PRINCIPLES    AND    PRACTICE    OF   PHYSIC. 

Third  American  edition,  revised,  with  Additions,  by  D.  Francis  Condie,  M.  D.,  author  of  a 


"  Treatise  on  the  Diseases  of  Children,"  &c. 

large  pages,  strongly  bound  with  raised  bands. 

To  say  that  it  is  the  very  best  work  on  the  sub- 
ject now  extant,  is  but  to  echo  the  sentiment  of  the 
medical  press  throughout  the  country.  —  N.  O. 
Medical  Journal. 

Of  the  text-books  recently  republished  Watson  is 
very  justly  the  principal  favorite. — Holmes's  Hep. 
to  Nat.  Med.  Assoc. 

By  universal  consent  the  work  ranks  among  the 
very  best  text-books  in  our  language. — Illinois  and 
Indiana  Med.  Journal. 

Regarded  on  all  hands  as  one  of  the  very  best,  if 
not  the  very  best,  systematic  treatise  on  practical 
medicine  extant. — St.  Louis  Med.  Journal. 


In  one  octavo  volume,  of  nearly  eleven  hundred 
$3  25. 

Confessedly  one  of  the  very  best  works  on  the 
principles  and  practice  of  physic  in  the  English  or 
any  other  language. — Med.  Examiner. 

Asa  text-book  it  has  no  equal;  as  a  compendium 
of  pathology  and  practice  no  superior. — New  York 
Annalist. 

We  know  of  no  work  better  calculated  for  being 
placed  in  the  hands  of  the  student,  and  for  a  text- 
book ;  on  every  important  point  the  author  seems 
to  have  posted  up  his  knowledge  to  the  day. — 
Amer.  Med.  Journal. 

One  of  the  most  practically  useful  books  that 
ever  was  presented  to  the  student.  —  N.  Y.  Med. 
Journal. 


WHAT    TO   OBSERVE 
AT    THE    BEDSIDE    AND    AFTER   DEATH,    IN    MEDICAL   CASES. 

Published  under  the  authority  of  the  London  Society  for  Medical  Observation.  A  new  American, 
from  the  second  and  revised  London  edition.  In  one  very  handsome  volume,  royal  12mo.,  extra 
cloth.     SI  00. 


To  the  observer  who  prefers  accuracy  to  blunders 
and  precision  to  carelessness,  this  little  book  is  in- 
raluable. — N.  II.  Journal  of  Medicine. 


One  of  the  finest  aids  to  a  young  practitioner  we 
have  ever  seen. — Peninsular  Journal  of  Medicine. 


AND    SCIENTIFIC    PUBLICATIONS  31 


WILSON    (ERASMUS),   M.D.,    F.  R.  S., 

Lecturer  on  Anatomy,  London. 

A  SYSTEM  OF  HUMAN  ANATOMY,  General  and  Special.  Fourth  Ameri- 
can, from  the  last  English  edition.  Edited  by  Paul  B.  Goddard,  A.  M.,  M.  D.  With  two  hun- 
dred and  filly  illustrations.  Beautifully  printed,  in  one  large  octavo  volume,  leather,  of  nearly 
six  hundred  pages.     $3  00. 

In  many,  if  not  all  the  Colleges  of  the  Union,  it 
has  become  a  standard  text-book.  This,  of  itself, 
is  sufficiently  expressive  of  its  value.     A  work  very 


It  offers  to  the  student  all  the  assistance  that  can 

be  expected  from  such  a  work. — Medical  Examiner. 

The  most  complete  and  COnVl  nienl  manual  for  the 


desirable  to  the  student;  one,  the  possession  of  *  i„  '" '  L'""l""c  "»"  convenient  imin,,;,  i  „,r  the 
which  will  greatly  facilitate  his  progress  in  the  '^  We  Posse8S—  Amertcan  Journal  of  Medical 
study  of  Practical  Anatomy. — New  York  Journal  of 

Medicine.  In   every   respect,   this  work  ns   an  anatomical 

guide  for  the  studenl  and   practitioner,  merits  our 
Its  author  ranks  with  the  highest  on  Anatomy.—     warmest  and  most  decided  praise.— London  Medical 
Southern  Medical  and  Surgical  Journal.  I  Gazette. 

BY   THE   SAME   AUTHOR.      (Just  IsSUed.) 

THE    DISSECTOR'S  MANUAL;  or,  Practical  and  Surgical  Anatomy.     Third 

American,  from  the  last  revised  and  flilarged  English  edition.  Modified  and  rearranged  by 
William  Hunt,  M.  U.,  Demonstrator  of  Anatomy  in  the  University  of  Pennsylvania.  In  one 
large  and  handsome  royal  12mo.  volume,  leather,  of  582  pages,  with  154  illustrations.  $2  00. 
The  modifications  and  additions  which  this  work  has  received  in  passing  recently  through  the 
author's  hands,  is  sufficiently  indicated  by  the  fact  that  it  is  enlarged  by  more  than  one  hundred 
pages,  notwithstanding  that  it  is  printed  m  smaller  type,  and  with  a  greatly  enlarged  page. 

It  remains  only  to  add,  that  after  a  careful  exami-  I  ing  very  superior  claims,  well  calculated  to  facilitate 
nation,  we  have  no  hesitation  in  recommending  this  |  their  studies,  and  render  their  labor  less  irksomi 
work  to  the  notice  of  those  for  whom  it  has  been  I  constantly  keeping  betore  them  definite  objects  of 
expressly  written— the  students— as  a  guide  possess-  |  interest. — The  Lancet. 

BY  the  same  author.     (Now  Ready,  May,  1S57.) 

ON  DISEASES  OF  THE  SKIN.     Fourth  and  enlarged  American,  from  the  last 

and  improved  London  edition.  In  one  large  octavo  volume,  of  650  pages,  extra  cloth,  $2  75, 
This  volume  in  passing  for  the  fourth  time  through  the  hands  of  the  author,  has  received  a  care- 
ful revision,  and  has  been  greatly  enlarged  and  improved.  About  one  hundred  and  fifty  pages  have 
been  added,  including  new  chapters  on  Classification,  on  General  Pathology,  on  GeneraT  Thera- 
peutics, on  Furuncular  Eruptions,  and  on  Diseases  of  the  Nails,  besides  extensive  additions  through- 
out the  text,  wherever  they  have  seemed  desirable,  either  from  former  omissions  or  from  the  pro- 
gress of  science  and  the  increased  experience  of  the  author.  Appended  to  the  volume  will  also 
now  be  found  a  collection  of  Selected  Formula,  consisting  for  the  most  part  of  prescriptions  ol 
which  the  author  has  tested  the  value. 

a  place  in  this  volume,  which,  without  a  doubt,  will, 
for  a  very  long  period,  be  acknowledged  ns  the  chief 
standard  work  on  dermatology.  The  principles  of 
an  enlightened  and  rational  therapeia  are  introduced 
on  every  appropriate  occasion.  The  general  prac- 
titioner and  surgeon  who,  peradventure,  may  have 
for  years  regarded  cutanrous  maladies  as  scarcely 
worthy  their  attention,  because,  forsooth,  they  are 
not  fatal  in  their  tendency;  or  who,  if  they  have 
attempted  their  cure,  have  followed  the  blind  guid- 
ance of  empiricism,  will  almost  assuredly  be  roused 
to  a  new  and  becoming  interest  in  this  department 
of  practice,  through  the  inspiring  agency  of  this 
book. — Am.  Jour.  Med.  Science,  Oct.  1857. 


The  writings  of  Wilson,  upon  diseases  of  the  skin, 
are  by  far  the  most  scientific  and  practical  that 
have  ever  been  presented  to  the  medical  world  on 
this  subject.  The  present  edition  isa  great  improve- 
ment on  all  its  predecessors.  To  dwell  upon  all  the 
great  merits  and  high  claims  of  the  work  before  us. 
seriatim,  would  indeed  be  an  agreeable  service  ;  it 
would  be  a  mental  homage  which  we  could  freely 
offer,  but  we  Ehould  thus  occupy  an  undue  amount 
of  space  in  this  Journal.  We  will,  howtver  look 
at  some  of  the  more  salient  points  with  which  it 
abounds,  and  which  make  it  incompars  bly  superior  in 
excellence  to  all  other  treatises  on  the  subject  of  der- 
matology.   No  mere  speculative  views  are  allowed 

also,  just  ready, 

A  SERIES  OF  PLATES  ILLUSTRATING  WILSON  ON  DISEASES  OF 

THE  SKIN  ;  consisting  of  nineteen  beautifully  executed  plates,  of  which  twelve  are  exquisitely 
colored,  presenting  the  Normal  Anatomy  and  Pathology  of  the  Skin,  and  containing  accurate  it- 
presentations  of  about  one  hundred  varieties  of  disease,  most  of  them  the  size  of  nature.  Price 
in  cloth  $4  25. 

In  beauty  of  drawing  and  accuracy  and  finish  of  coloring  these  plates  will  be  found  superior  u> 
anything  of  the  kind  as  yet  issued  in  this  country. 

The  plates  by  which  this  edition  is  accompanied  The  representations  of  the  various  forms  of  cutnne- 
leave  nothing  to  be  desired,  so  far  as  excellence  of  ous  disease  are  singularly  accurate,  and  the  coloring 
delineation  and  perfect  accuracy  of  illustration  are  exceeds  almost  anything  we  have  met  with  in  point 
concerned. — Medico-Chirurgical  Review.  of  delicacy  and  finish. — British  and  Foreign  Medical 

Of  these  plates  it  is  impossible  to  speak  too  highly.     ««**«**•. 

BY  THE   SAME  AUTHOR. 

ON    CONSTITUTIONAL    AND    HEREDITARY    SYPHILIS,   AND    ON 

SYPHILITIC  ERUPTIONS.  In  one  small  octavo  volume,  exlra  cloth,  beautifully  printed,  with 
four  exquisite  colored  plates,  presenting  more  than  thirty  varieties  of  syphilitic  eruption-.  $2  25. 

by  the  same  author.     (Just  Issued.) 

HEALTHY  SKIN;  A  Popular  Treatise  on  the  Skin  and  Hair,  their  Preserva- 
tion and  Management.  Second  American,  from  the  fourth  London  edition.  One  neat  volume, 
royal  12rno.:  extra  cloth,  of  about  300  pages,  with  numerous  illustrations.  $1  00  ;  paper  cover, 
75  cents. 

WILDE   (W.    R.), 

Surgeon  to  St.  Mark's  Ophthalmic  and  Aural  Hospital,  Dublin. 

AURAL  SURGERY,  AND  THE  NATURE  AND  TREATMENT  OF  DIS- 
EASES OF  THE  EAR.      In  one  handsome  octavo  volume,  extra  cloth,  of  476  pages,  with 

illustrations.     $2  80. 


32  BLANCHARD   <fc    LEA'S    MEDICAL    PUBLICATIONS. 


WEST   (CHARLES),    M.  D., 
Accoucheur  to  and  Leetunr  on  Midwifery  at  St.  Bartholomew'!  Hospital,  Physician  to  the  Hospital  for 

^irk  Children,  &c. 

LECTURES   ON   THE    DISEASES    OF   INFANCY  AND  CHILDHOOD. 

Second  American,  from  the  Second  and  Enlarged  London  edition.      In  one  volume,  octavo, 
extra  cloth,  <>i  nearly  five  hundred  pagea.    98  <>u. 


ligation  by  (his  able,  thorough,  and  finished  work 
upon  ii  subject  which  almost  daily  taxes  to  the  ut- 
mOBt  the-  skill  of  the  general  practitioner.  He  tins 
with  siiiun  1-- r  felicity  threaded  ins  way  through  all 
the  toTtoons  labyrinths  of  the  difficult  subject  he  has 
undertaken  to  elucidate,  and  has  in  many  of  the 
darkest  corners  left  a  light,  which  will  never  be 
extinguished. — XnthvilU  Medical  Journal. 


We  take  leave  of  Dr.  West  with  great  respect  for 

his  attainments,  a  due  appreciation  .of  ins  acute 
powers  of  observation,  and  a  deep  sense  of  obliga- 
tion for  this  valuable  contribution  to  our  profes- 
sional literature.     His  book  is  undoubtedly  i any 

respects  th<  besl  we  possess  on  diseases  of  children. 
Dublin  Quartt  rly  Journal  of  Medical  S<  u  net. 
Dr.  West  tins  placed  the  profession  under  deep  ob« 

BY   THE   SAME   AUTHOR.      (Just  Issued.) 

LECTURES  ON  THE  DISEASES  OF  WOMEN.     In  two  parts. 

Part  1.  Svo.  cloth,  of  about  300  pages,  comprising^!*  Diseases  of  the  Uterus.     SI  GO. 
Bart  II.  {Preparing))  will  contain  Diseases  of  the  Ovaries,  and  of  all  the  parts,  connected 

■with  the  Uteris;  of  the  Bladder,  Vagina,  and  External  Organs. 
The  objoct  of  the  author  in  this  work  is  to  present  a  complete  but  succinct  treatise  on  Female 
Diseases,  embodying  the  results  of  his  experience  during  the  last  ten  years  at  St.  Bartholomew's 
and  the  Midwilery  Hospitals,  a^  well  as  in  private  practice.  The  characteristics  which  have  se- 
cured to  his  former  works  so  favorable  a  reception,  cannot  fail  to  render  the  present  volume  a 
standard  authority  on  its  important  subject.  To  show  the  general  scope  of  the  work,  an  outline  of 
the  Contents  of  Bart  I.  is  subjoined. 

Lectures  I ,  II. — Introductory — Symptoms — Examination  of  Symptoms — Modes  of  Examina- 
tions. Lectures  III.,  IV.,  V  — Disorders  of  Menstruation,  Amenorrhea,  Menorrhagia,  Dys- 
menorrhea. Lectures  VI.,  VII,  VIII. — Inflammation  of  the  Uterus,  Hypertrophy,  Acute 
Inflammation,  Chronic  Inflammation,  Ulceration  of  the  Os  Uteri,  Cervical  Leucorrhcea.  Lectures 
IX.,  X.,  XI,  XIL,  XIII. — Misplacement  of  the  Uterus,  Prolapsus,  Anteversion,  Retrover- 
sion, Inversion.  Lectures  XIV.,  XV.,  XVI.,  XVII. — Uterine  Tumors  and  Outgrowths, 
Mucous,  Fibro-cellular,  and  Glandular  Polypi.  Mucous  Cysts,  Fibrinous  Polypi.  Fibrous  Tumors, 
Fibrous  Polypi,  Fatty  Tumors,  Tubercular  Diseases.  Lectures  XV III.,  XIX.,  XX. — Cancer 
of  the  Uterus. 
Part  II.  will  receive  an  equally  extended  treatment,  rendering  the  whole  an  admirable  text-book 
lor  the  student,  and  a  reliable  work  for  reference  by  the  practitioner. 

by  the  same  author.     (Just  Issued) 

AN  ENQUIRY  INTO  THE  PATHOLOGICAL  IMPORTANCE  OF  ULCER- 
ATION OF  THE  OS  UTERI.    In  one  neat  octavo  volume,  extra  cloth.    $1  00. 


WILLIAMS  (C.   J.   B.),    M.  D.,    F.  R.  S., 

Professor  of  Clinical  Medicine  in  University  College,  London,  &c. 

PRINCIPLES  OF  MEDICINE.     An  Elementary  View  of  the  Causes,  Nature, 

Treatment,  Diagnosis,  and  Prognosis  of  Disease;  with  brief  remarks  on  Hygienics,  or  the  pre- 
servation of  health.  A  new  American,  from  the  third  and  revised  London  edition.  In  one  octavo 
volume,  leather,  of  about  500  pages.     $2  50.     (Now  Ready,  May,  1857.) 

The  very  recent  and  thorough  revision  which  this  work  has  enjoyed  at  the  hands  of  the  author 
has  brought  it  so  completely  up  to  the  present  state  of  the  subject  that  in  reproducing  it  no  i  dditions 
have  been  (bund  necessary.  The  success  which  the  work  has  heretofore  met  shows  that  its  im- 
portance has  been  appreciated,  and  in  its  present  form  it  will  be  found  eminently  worthy  a  continu- 
ance of  the  same  favor,  possessing  as  it  does  the  strongest  claims  to  the  attention  of  the  medical 
student  and  practitioner,  from  the  admirable  manner  in  which  the  various  inquiries  in  the  different 
branches  of  pathology  are  investigated,  combined  and  generalized  by  an  experienced  practical  phy- 
sician, and  directly  applied  to  the  investigation  and  treatment  of  disease. 

recommend  it  for  a  text-book,  guide,  and  constant 


We  find  that  the  deeply-interesting  matter  and 
style  of  this  hook  have  so  far  fascinated  us,  that  we 
have  unconsciously  hung  upon  its  pages,  not  too 
long,  indeed,  for  our  own  profit,  hut  longer  than  re- 
viewers can  he  permitted  to  indulge.  We  leave  the 
further  analysis  to  the  student  and  practitioner.  Our 
judgment  of  the  work  has  already  been  sufficiently 
expressed.  It  is  a  judgment  of  almost  unqualified 
praise.  The  work  is  not  of  a  controversial,  but  of 
a  didactic  character;  and  as  such  we  hail  it,  and 


companion  to  every  practitioner  and  every  student 
who  wishes  to  extricate  himself  from  the  well-worn 
ruts  of  empiricism,  and  to  base  his  practice  of  medi- 
cine upon  principles. — London  Lancet,  Dec.  27,  1S56. 

A  text-book  to  which  no  other  in  our  language  is 
comparable. — Charleston  Medical  Journal. 

No  work  has  ever  achieved  or  maintained  a  more 
deserved  reputation. —  Va.  Med.  and  Surg.  Journal. 


WHITEHEAD  ON  THE  CAUSES  AND  TREAT-  I      Second  American  Edition.     In  one  volume,  octa- 
MENT   OP    ABORTION    AND   STERILITY.  |      vo,  extra  cloth,  pp.  308.     $1    75. 


YOUATT  (WILLIAM),  V.  S. 
THE    HORSE.     A  new  edition,  with  numerous  illustrations;   together  with  a 

general  history  of  the  Horse;  a  Dissertation  on  the  American  Trotting  Horse;  how  Trained  and 
Jockeyed;  an  Account  of  his  Remarkable  Performances;  and  an  Essay  on  the  Ass  and  the  Mule. 
By  3.  H.  Skinner,  formerly  Assistant  Postmaster-General,  and  Editor  of  the  Turf  Register. 
One  large  octavo  volume,  extra  cloth.     $1  50. 

by  the  same  author. 

THE   DOG.     Edited  by  E.  J.  Lewis,   M.  D.     With   numerous  and  beautiful 
illustrations     In  one  very  handsome  volume,  crown  Svo.,  crimson  cloth,  gilt.  $1  25. 


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